key: cord-322534-eikz07zz authors: allahyari, abolghasem; rahimi, hossein; khadem-rezaiyan, majid; mozaheb, zahra; seddigh-shamsi, mohsen; bary, alireza; kamandi, mostafa; azimi, sajad ataei; hasanabadi, saeed eslami; noferesti, alireza; shariatmaghani, somayeh sadat; rafatpanah, houshang; khatami, shohreh; imani, afshin jabbar; mortazi, hassan; nodeh, mohammad moeini title: effect of hydroxychloroquine on covid-19 prevention in cancer patients undergoing treatment: a structured summary of a study protocol for a randomised controlled trial date: 2020-06-26 journal: trials doi: 10.1186/s13063-020-04485-x sha: doc_id: 322534 cord_uid: eikz07zz objectives: in this study, we investigate the effect of hydroxychloroquine on the prevention of novel coronavirus disease (covid-19) in cancer patients being treated. trial design: this is a multi-centre, two-arm, parallel-group, triple-blind, phase 2-3 randomised controlled trial. participants: all patients over the age of 15 from 5 types of cancer are included in the study. patients with acute lymphoid and myeloid leukemias in the first line treated with curative intent, patients with high-grade non-hodgkin's lymphoma treated with leukemia protocols and patients with non-metastatic breast and colon cancer in the first line of treatment will enter the study. the exclusion criteria will include known sensitivity to hydroxychloroquine, weight below 35 kilograms, history of retinopathy, history of any cardiac disease, acute respiratory tract infection in the last 2 months, having covid-19 in the first two weeks of entering the trial, having diabetes mellitus, having an immuno-suppressive disease other than cancer, having chronic pulmonary disease and taking immuno-suppressant drug other than chemotherapeutic agents for current cancer. this study is performed in five academic centres affiliated to mashhad university of medical sciences, mashhad, iran. intervention and comparator: patients are randomly assigned to two groups; one being given hydroxychloroquine and the other is given placebo. during two months of treatment, the two groups are treated with either hydroxychloroquine (amin® pharmaceutical company, isfahan, iran) or placebo (identical in terms of shape, colour, smell) as a single 200 mg tablet every other day. patients will be monitored for covid-19 symptoms during the follow-up period. if signs or symptoms occur (fever, cough, shortness of breath), they will be examined and investigated with a high-resolution computed tomography (ct) scan of the lungs, covid-19 specific igm, igg antibody assay and a nucleic acid amplification test (nat) for the sars-cov-2 virus. main outcomes: the primary end point of this study is to investigate the incidence of covid-19 in patients being treated for their cancer over a 2-month period. randomisation: randomisation will be performed using randomly permuted blocks. by using an online website (www.randomization.com) the randomization sequence will be produced by quadruple blocks. the allocation ratio in intervention and control groups is 1:1. blinding (masking): participants and caregivers do not know whether the patient is in the intervention or the control group. the outcome assessor and the data analyst are also blinded to group assignment. numbers to be randomised (sample size): the calculated total sample size is 60 patients, with 30 patients in each group. trial status: the trial began on april 14, 2020 and recruitment is ongoing. recruitment is anticipated to be completed by june 14, 2020 there has been no change in study protocol since approval, protocol version 1 was approved april 12, 2020. trial registration: this trial has been registered by the title of “effect of hydroxychloroquine on novel coronavirus disease (covid-19) prevention in cancer patients under treatment” in iranian registry of clinical trials (irct) with code “irct20200405046958n1”, https://www.irct.ir/trial/46946. registration date is april 14, 2020. full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. intervention and comparator: patients are randomly assigned to two groups; one being given hydroxychloroquine and the other is given placebo. during two months of treatment, the two groups are treated with either hydroxychloroquine (amin® pharmaceutical company, isfahan, iran) or placebo (identical in terms of shape, colour, smell) as a single 200 mg tablet every other day. patients will be monitored for covid-19 symptoms during the follow-up period. if signs or symptoms occur (fever, cough, shortness of breath), they will be examined and investigated with a high-resolution computed tomography (ct) scan of the lungs, covid-19 specific igm, igg antibody assay and a nucleic acid amplification test (nat) for the sars-cov-2 virus. main outcomes: the primary end point of this study is to investigate the incidence of covid-19 in patients being treated for their cancer over a 2-month period. randomisation: randomisation will be performed using randomly permuted blocks. by using an online website (www.randomization.com) the randomization sequence will be produced by quadruple blocks. the allocation ratio in intervention and control groups is 1:1. blinding (masking): participants and caregivers do not know whether the patient is in the intervention or the control group. the outcome assessor and the data analyst are also blinded to group assignment. numbers to be randomised (sample size): the calculated total sample size is 60 patients, with 30 patients in each group. trial status: the trial began on april 14, 2020 and recruitment is ongoing. recruitment is anticipated to be completed by june 14, 2020 there has been no change in study protocol since approval, protocol version 1 was approved april 12, 2020. trial registration: this trial has been registered by the title of "effect of hydroxychloroquine on novel coronavirus disease (covid-19) prevention in cancer patients under treatment" in iranian registry of clinical trials (irct) with code "irct20200405046958n1", https://www.irct.ir/trial/46946. registration date is april 14, 2020. full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. keywords: covid-19, randomised controlled trial, protocol, hydroxychloroquine, acute lymphoid leukemia, acute myeloid leukemia, breast cancer, colon cancer, prophylaxis supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04485-x. additional file 1. ghaem hospital, ahmadabad ave, shariati sq publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank the vice chancellor for research of mashhad university of medical sciences for supporting this project. also, the help of clinical research development unit of akbar hospital (affiliated to mashhad university of medical sciences, mashhad, iran) in designing the study and methodological issues is highly appreciated. all the financial resources required for this project have been provided by the vice-chancellor for research of mashhad university of medical sciences (code:990046). the funding body has no role in the design of this study, collection, analysis, and interpretation of data and in writing the manuscript. the final dataset of the trial will be available upon request from the primary investigator via e-mail at moeininm@mums.ac.ir, after obtaining the permission of the regional ethics committee. the trial has been approved by the ethical committee of mashhad university of medical sciences, iran. ethics committee reference number is ir.mums.rec.1399.078 which was registered on april 12, 2020. (publicly available at this link) hereby we certify that this trial has received ethical approval from the aforementioned ethical committee as described above. an informed consent is obtained from all participants or their legal guardians prior to recruitment. not applicable. the authors declare that they have no competing interests. key: cord-293440-qoo2t1wt authors: wilkinson, tom; dixon, rupert; page, clive; carroll, miles; griffiths, gareth; ho, ling-pei; de soyza, anthony; felton, timothy; lewis, keir e.; phekoo, karen; chalmers, james d.; gordon, anthony; mcgarvey, lorcan; doherty, jillian; read, robert c.; shankar-hari, manu; martinez-alier, nuria; o’kelly, michael; duncan, graeme; walles, roelize; sykes, james; summers, charlotte; singh, dave title: accord: a multicentre, seamless, phase 2 adaptive randomisation platform study to assess the efficacy and safety of multiple candidate agents for the treatment of covid-19 in hospitalised patients: a structured summary of a study protocol for a randomised controlled trial date: 2020-07-31 journal: trials doi: 10.1186/s13063-020-04584-9 sha: doc_id: 293440 cord_uid: qoo2t1wt objectives: stage 1: to evaluate the safety and efficacy of candidate agents as add-on therapies to standard of care (soc) in patients hospitalised with covid-19 in a screening stage. stage 2: to confirm the efficacy of candidate agents selected on the basis of evidence from stage 1 in patients hospitalised with covid-19 in an expansion stage. trial design: accord is a seamless, phase 2, adaptive, randomised controlled platform study, designed to rapidly test candidate agents in the treatment of covid-19. designed as a master protocol with each candidate agent being included via its own sub-protocol, initially randomising equally between each candidate and a single contemporaneous soc arm (which can adapt into 2:1). candidate agents currently include bemcentinib, medi3506, acalabrutinib, zilucoplan and nebulised heparin. for each candidate a total of 60 patients will be recruited in stage 1. if stage 1 provides evidence of efficacy and acceptable safety the candidate will enter stage 2 where a total of approximately 126 patients will be recruited into each study arm sub-protocol. enrollees and outcomes will not be shared across the stages; the endpoint, analysis and sample size for stage 2 may be adjusted based on evidence from stage 1. additional arms may be added as new potential candidate agents are identified via candidate agent specific sub-protocols. participants: the study will include hospitalised adult patients (≥18 years) with confirmed sars-cov-2 infection, the virus that causes covid-19, that clinically meet grades 3 (hospitalised – mild disease, no oxygen therapy), grades 4 (hospitalised, oxygen by mask or nasal prongs) and 5 (hospitalised, non-invasive ventilation or high flow oxygen) of the who working group on the clinical characteristics of covid-19 9-point category ordinal scale. participants will be recruited from england, northern ireland, wales and scotland. intervention and comparator: comparator is current standard of care (soc) for the treatment of covid-19. current candidate experimental arms include bemcentinib, medi3506, acalabrutinib, zilucoplan and nebulised heparin with others to be added over time. bemcentinib could potentially reduce viral infection and blocks sars-cov-2 spike protein; medi3506 is a clinic-ready anti-il-33 monoclonal antibody with the potential to treat respiratory failure caused by covid; acalabrutinib is a btk inhibitor which is anti-viral and anti-inflammatory; zilucoplan is a complement c5 inhibitor which may block the severe inflammatory response in covid-19 and; nebulised heparin has been shown to bind with the spike protein. accord is linked with the uk national covid therapeutics task force to help prioritise candidate agents. main outcomes: time to sustained clinical improvement of at least 2 points (from randomisation) on the who 9-point category ordinal scale, live discharge from the hospital, or considered fit for discharge (a score of 0, 1, or 2 on the ordinal scale), whichever comes first, by day 29 (this will also define the “responder” for the response rate analyses). randomisation: an electronic randomization will be performed by cenduit using interactive response technology (irt). randomisation will be stratified by baseline severity grade. randomisation will proceed with an equal allocation to each arm and a contemporaneous soc arm (e.g. 1:1 if control and 1 experimental arm; 1:1:1 if two experimental candidate arms etc) but will be reviewed as the trial progresses and may be changed to 2:1 in favour of the candidate agents. blinding (masking): the trial is open label and no blinding is currently planned in the study. numbers to be randomised (sample size): this will be in the order of 60 patients per candidate agent for stage 1, and 126 patients for stage 2. however, sample size re-estimation may be considered after stage 1. it is estimated that up to 1800 patients will participate in the overall study. trial status: master protocol version accord-2-001 master protocol (amendment 1) 22(nd) april 2020, the trial has full regulatory approval and recruitment is ongoing in the bemcentinib (first patient recruited 6/5/2020), medi3506 (first patient recruited 19/5/2020), acalabrutinib (first patient recruited 20/5/2020) and zilucoplan (first patient recruited 19/5/2020) candidates (and soc). the recruitment dates of each arm will vary between candidate agents as they are added or dropped from the trial, but will have recruited and reported within a year. trial registration: eudract 2020-001736-95, registered 28(th) april 2020. full protocol: the full protocol (master protocol with each of the candidate sub-protocols) is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. (continued from previous page) participants: the study will include hospitalised adult patients (≥18 years) with confirmed sars-cov-2 infection, the virus that causes covid-19, that clinically meet grades 3 (hospitalisedmild disease, no oxygen therapy), grades 4 (hospitalised, oxygen by mask or nasal prongs) and 5 (hospitalised, non-invasive ventilation or high flow oxygen) of the who working group on the clinical characteristics of covid-19 9-point category ordinal scale. participants will be recruited from england, northern ireland, wales and scotland. intervention and comparator: comparator is current standard of care (soc) for the treatment of covid-19. current candidate experimental arms include bemcentinib, medi3506, acalabrutinib, zilucoplan and nebulised heparin with others to be added over time. bemcentinib could potentially reduce viral infection and blocks sars-cov-2 spike protein; medi3506 is a clinic-ready anti-il-33 monoclonal antibody with the potential to treat respiratory failure caused by covid; acalabrutinib is a btk inhibitor which is anti-viral and anti-inflammatory; zilucoplan is a complement c5 inhibitor which may block the severe inflammatory response in covid-19 and; nebulised heparin has been shown to bind with the spike protein. accord is linked with the uk national covid therapeutics task force to help prioritise candidate agents. main outcomes: time to sustained clinical improvement of at least 2 points (from randomisation) on the who 9point category ordinal scale, live discharge from the hospital, or considered fit for discharge (a score of 0, 1, or 2 on the ordinal scale), whichever comes first, by day 29 (this will also define the "responder" for the response rate analyses). randomisation: an electronic randomization will be performed by cenduit using interactive response technology (irt). randomisation will be stratified by baseline severity grade. randomisation will proceed with an equal allocation to each arm and a contemporaneous soc arm (e.g. 1:1 if control and 1 experimental arm; 1:1:1 if two experimental candidate arms etc) but will be reviewed as the trial progresses and may be changed to 2:1 in favour of the candidate agents. the trial is open label and no blinding is currently planned in the study. numbers to be randomised (sample size): this will be in the order of 60 patients per candidate agent for stage 1, and 126 patients for stage 2. however, sample size re-estimation may be considered after stage 1. it is estimated that up to 1800 patients will participate in the overall study. trial status: master protocol version accord-2-001 -master protocol (amendment 1) 22 nd april 2020, the trial has full regulatory approval and recruitment is ongoing in the bemcentinib (first patient recruited 6/5/2020), medi3506 (first patient recruited 19/5/2020), acalabrutinib (first patient recruited 20/5/2020) and zilucoplan (first patient recruited 19/5/2020) candidates (and soc). the recruitment dates of each arm will vary between candidate agents as they are added or dropped from the trial, but will have recruited and reported within a year. trial registration: eudract 2020-001736-95, registered 28 th april 2020. full protocol: the full protocol (master protocol with each of the candidate sub-protocols) is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. keywords: covid-19, randomised, platform study, master protocol, phase ii supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04584-9. additional file 1. l-ph has received research grants from boehringer ingleheim and celgene. kl is medical director of respiratory innovation wales and a director of bond digital health and iomics ltd and has received sponsorship to attend and speak at international meetings from astrazeneca, boehringer ingelheim, glaxosmithkline and pfizer. tf has received sponsorship to attend and speak at international meetings, honoraria for lecturing or attending advisory boards, from gilead, pfizer and menarini and is an advisor to the nice/nhse amr novel antimicrobial value assessment/reimbursement project stakeholder advisory group. tw has received research grants/personal frees/travel from astrazeneca 14 evelina london children's hospital guy's and st thomas publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we acknowledge the university hospital southampton nhs foundation trust who are the sponsor for accord. we also acknowledge the involvement of the nihr community in developing and conducting the accord, including but not limited to the nihr respiratory translational research collaboration, nihr biomedical research centres and nihr clinical research facilities. authors' contributions tw, ds, cp, mc, nm-a, mo and rd came up with the concept of the development of accord and oversaw the development of the master protocol and this submission. tw, ds, cp, l-ph, ads, tf, kl, kp, ic, ag, lm, jd, rr, m-sh, cs & gg are accord steering committee members overseeing the coordination of accord and the protocol. mo and js were responsible for the development of the statistical design and with gg the statistical aspects of running and analysing the trial. rw and gd were responsible for developing the trial management and delivery aspects of the trial. all were involved in the development of the master protocol and this submission. the author(s) read and approved the final manuscript. the accord trial platform is funded by ukri. the funder will have no role in the study's design, collection, management, analysis and interpretation of data, writing of the report and the decision to submit the report for publication conception or in the data analysis. when the database from each candidate sub-protocol is locked, analysed and published we will make the data available to the academic community via www.clinicalstudydatarequest.com.ethics approval and consent to participate health research authority and research ethics committee, bristol hra centre (rec reference: 20/sc/0201), 24 th april 2020 i certify that this trial has received appropriate ethical approval as described above. we will obtain consent from all participants entering into the accord study. not applicable key: cord-302448-2r4rtixg authors: kharma, nadir; roehrig, stefan; shible, ahmed atef; elshafei, moustafa sayed; osman, dema; elsaid, ingi mohamed; mustafa, salma faisal; aldabi, asjad; smain, osamah a.m.; lance, marcus d. title: anticoagulation in critically ill patients on mechanical ventilation suffering from covid-19 disease, the anti-co trial: a structured summary of a study protocol for a randomised controlled trial date: 2020-09-07 journal: trials doi: 10.1186/s13063-020-04689-1 sha: doc_id: 302448 cord_uid: 2r4rtixg objectives: to assess the effect of anticoagulation with bivalirudin administered intravenously on gas-exchange in patients with covid-19 and respiratory failure using invasive mechanical ventilation. trial design: this is a single centre parallel group, superiority, randomized (1:1 allocation ratio) controlled trial. participants: all patients admitted to the hamad medical corporation -icu in qatar for covid-19 associated respiratory distress and in need of mechanical ventilation are screened for eligibility. inclusion criteria: all adult patients admitted to the icu who test positive for covid-19 by pcr-test and in need for mechanical ventilation are eligible for inclusion. upon crossing the limit of d-dimers (1.2 mg/l) these patients are routinely treated with an increased dose of anticoagulant according to our local protocol. this will be the start of randomization. exclusion criteria: pregnancy, allergic to the drug, inherited coagulation abnormalities, no informed consent. intervention and comparator: the intervention group will receive the anticoagulant bivalirudin intravenously with a target aptt of 45-70 sec for three days while the control group will stay on the standard treatment with low-molecular-weight heparins /unfractionated heparin subcutaneously (see scheme in additional file 1). all other treatment will be unchanged and left to the attending physicians. main outcomes: as a surrogate parameter for clinical improvement and primary outcome we will use the pao2/fio2 (p/f) ratio. randomisation: after inclusion, the patients will be randomized using a closed envelope method into the conventional treatment group, which uses the standard strategy and the experimental group which receives anticoagulation treatment with bivalirudin using an allocation ratio of 1:1. blinding (masking): due to logistical and safety reasons (assessment of aptt to titrate the study drug) only the data-analyst will be blinded to the groups. numbers to be randomised (sample size): we performed a sample size calculation and assumed the data for p/f ratio (according to literature) is normally distributed and used the mean which would be: 160 and sd is 80. we expect the treatment will improve this by 30%. in order to reach a power of 80% we would need 44 patients per group (in total 88 patients). taking approximately 10% of dropout into account we will include 100 patients (50 in each group). trial status: the local registration number is mrc-05-082 with the protocol version number 2. the date of approval is 18th june 2020. recruitment started on 28(th) june and is expected to end in november 2020. trial registration: the protocol is registered before starting subject recruitment under the title: “anticoagulation in patients suffering from covid-19 disease. the anti-co trial” in clinicaltrials.org with the registration number: nct04445935. registered on 24 june 2020. full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 2). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. list abbreviations, acronyms and terms of reference used in the protocol; provide definitions for each as needed the pandemic of covid-19, a newly upcoming viral disease caused by sars-cov-2, puts the whole worlds health system under pressure. patients suffering from this disease mainly develop respiratory symptoms, which can lead to severe acute respiratory distress syndrome (ards) necessitating icu admission in 10-20% of the cases admitted to hospital. in addition to these symptoms, patients show lymphopenia, cardiac symptoms and altered coagulation profiles. although those patients are treated in the icu the mortality there is more than 20% due to multiorgan failure [1, 2]. one of the recent insights in this disease is its effect on the coagulation system. meanwhile we know that the coagulation system gets activated. furthermore, it seems that clot formation takes place in the pulmonary micro-vasculature which could contribute to the widely observed gasexchange impairment. therefore, many centers apply empiric anticoagulation for their covidpatients. at the moment, we at hmc, also apply an empirical anticoagulation protocol as our standard approach (see attachment 1). however, this is a symptomatic treatment without good proof. bivalirudin is a well-known agent which is used in hmc for cases in which anticoagulation is needed, but a contraindication for heparin exists (i.e. hit syndrome). this drug has an interesting pharmacologic profile. it acts independent of antithrombin (at), the physiological compound which enhances heparin effects under normal circumstances. this lack of dependence on at, makes bivalirudin an attractive choice in light of the contradictory reports on the levels of at during covid infection. if at levels are decreased during the infection, heparin (as well as lmwh) cannot work efficiently, which would render our treatment less effective. luckily, bivalirudin acts without the support of at, so we could bypass this problem. in addition, bivalirudin has some fibrinolytic activities. it inhibits clot-bound thrombin which as a result destabilizes the clot rendering it more susceptible to thrombolysis. this property partially supports the dissolving of clots and could support re-opening the pulmonary microcirculation. [3, 4] objectives: to prove the positive effect of anticoagulation with bivalirudin intravenously on gas-exchange in patients with covid-19 and respiratory failure on invasive mechanical ventilation. as a surrogate parameter for clinical improvement we will use the pao2/fio2 ratio. clinically parameters (e.g. time to extubation, ventilator settings) all patients coming to admission to the icu for covid associated respiratory distress and in need for mechanical ventilation according to clinical decision are screened for eligibility. inclusion criteria: all adult patients admitted to the icu who are covid positive tested and in need for mechanical ventilation are eligible for inclusion. upon crossing the limit of d-dimers (1.2 mg/l) these patients would be standardly treated with an increased does of anticoagulant. this would be the start of randomization. exclusion criteria: pregnancy, allergic to the drug, inherited coagulation abnormalities, no informed consent. after inclusion the patients will be randomized using a closed envelope method into the conventional treatment group (see attached protocol), which uses the hmgh-approved strategy and the experimental group which receives anticoagulation treatment with bivalirudin (see attached hit-protocol). as a safety measure we will monitor and titrate all drugs according to the aptt and/or antixa (according to the protocols-see attachment). we will collect demographic data (age, sex, bmi), co-morbidities and clinical data (need for special intervention e.g. proning). next to the vital parameters (blood pressure, heart frequency and body temperature) the oxygenation parameters and etco2 will be collected. the standard coagulation parameters (aptt, inr, platelet count, antixa) will be collected. in addition, we monitor fibrinogen levels and d-dimers (both are associated with mortality) and at. kidney-function parameters (creatinine, urea), liver function tests and whole blood counts and immune-parameters like interleukin 6 (il-6) will be recorded. cardiac enzymes will be collected (troponin, bnp) and echocardiography will be evaluated and reported. all of these parameters are reported routinely on daily base for clinical purpose. power-calculation: grasselli et al. found that the median pf ratio was 160 with (iqr114-220) in their cohort of 1591 patients. [2] to perform sample size calculation, we assume data is normally distributed and set the median equal to mean (mean=median and sd = iqr/1.35). so, the mean would be: 160 and sd is 80. we expect the treatment will improve this by 30%. in order to reach a power of 80% we would need 44 patients per group (in total 88 patients). taking approximately 10% of exclusion into account we will include 100 patients (50 in each group). data analysis: categorical data will be presented as number and percentage, while interval data will be presented by median and interquartile range (iqr). normally distributed data will be analyzed by using two-tailed unpaired students t-test. continuous variables with skewed distribution will be analyzed using mann-whitney u testing and dichotomous variables by means of fisher's exact test. a p-value <0.05 is considered significant. all data analyses will be done using spss version v23 (ibm corp, armonk ny, usa). graphs will be constructed using graphpad prism (graphpad prism version 5.0a for windows, graphpad software, san diego ca, usa). we will maintain privacy for the subject throughout data collection by carrying out data collection in private rooms (icu-rooms). data confidentiality will be maintained by the use of study ids rather than any identifying data. all data will be entered into a secure database, which is password protected with restricted access, only assigned by the research team. each subject will be assigned an alphanumeric study id, to ensure data confidentiality. the link between the identifier and the study code will be deleted at the end of the study and the anonymized data set will be kept for at least 5 years after study completion per mrc policy. subjects can withdraw from the study at any point and this will not be held against them. they will be informed during the consent process of this and will be asked to contact the research team so that the investigator can withdraw them from the study. if a subject should withdraw, the data and samples collected will be destroyed, unless they have already been analyzed or processed or coded. this study is an interventional trial using anticoagulants. the anticoagulant used (bivalirudin) principally is registered and fda approved for the use as a direct thrombin inhibitor in adults undergoing percutaneous coronary interventions and in patients with heparin induced thrombocytopenia. as with all medication this medication might also show side effects. next to allergic reaction the most prominent could be bleeding. as a bleeding might be a severe side effect, data after the first 5 patients will be reviewed by the dsmb. if the major bleeding rate exceeds the numbers reported in literature (3.1%) we will be forced to stop the study prematurely due to safety concerns. although the research drug (bivalirudin) is an old drug which is approved and used widely we will follow and report all adverse effects to ensure safety for the patients. case-fatality rate and characteristics of patients dying in relation to covid-19 in italy baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region argatroban and bivalirudin for perioperative anticoagulation in cardiac surgery the direct thrombin inhibitors (argatroban, bivalirudin and lepirudin) and the indirect xa-inhibitor (danaparoid) increase fibrin network porosity and thus facilitate fibrinolysis the members of the research team act according to the gcp guidelines. all research is done under recognition of the helsinki declaration and under full adherence to the moph regulations in qatar. key: cord-315175-51wuz9i1 authors: kaddam, lamis; babiker, rasha; ali, sara; satti, shahinaz; ali, nour; elamin, maha; mukhtar, mowaia; elnimeiri, mustafa; saeed, amal title: potential role of acacia senegal (gum arabic) as immunomodulatory agent among newly diagnosed covid 19 patients: a structured summary of a protocol for a randomised, controlled, clinical trial date: 2020-09-05 journal: trials doi: 10.1186/s13063-020-04707-2 sha: doc_id: 315175 cord_uid: 51wuz9i1 objectives: to investigate the potential efficacy of acacia senegal extract gum arabic (ga) supplementation as immunomodulatory and anti-inflammatory dietary intervention among newly diagnosed covid 19 sudanese patients. to study the effect of ga on the level of cytokines, tnfα, il8, il6 il10, crp and the viral load. secondary outcomes will be the effect of ga oral intake on mortality rate and days of hospital admission. trial design: quadruple blind, randomized placebo-controlled clinical trial phase ii & iii. prospective, two-arm, parallel-group, randomised (1:1 allocation ratio) superiority trial of oral ga among seropositive covid-19 patients. participants: inclusion criteria: covid-19 infected (newly diagnosed) as proved by real-time pcr within 72 hours of pcr. age 8-90 years both genders exclusion criteria: intubated patients on parenteral treatment allergy to gum arabic the study will be conducted in covid isolation centres and soba university hospital khartoum state sudan. intervention and comparator: experimental: intervention group this arm will receive 100% natural gum arabic provided in a powder form in 30-grams-dose once daily for four weeks placebo comparator: control group: this group will be provided with pectin powder provided as one-gram-dose once daily for four weeks both ga and placebo will be in addition to standard care treatment based on local clinical guidelines. main outcomes: mean change from baseline score of immune response to end of the trial. changes of the level of tumor necrosis factor (tnfα), interleukin il8, il6, and il10 from the baseline values (four weeks from the start of randomization). mortality rate: the percentage of deaths among covid 19 patients received gum arabic compared to placebo (four weeks from the start of randomization]). randomisation: randomization (1:1 allocation ratio) and will be conducted using a sequence of computer-generated random numbers by an independent individual. each participating centre will be assigned a special code generated by the computer. the randomization will be kept by the pi and a research assistant. blinding (masking): quadruple (participant, care provider, investigator, outcomes assessor) numbers to be randomised (sample size): 110 eligible patients will be randomly assigned to either ga (n=55) or placebo (n=55) groups. trial status: protocol version no 2, 30(th) june 2020. recruitment will start on 15(th) september 2020. the intended completion date is 15(th) january 2021. trial registration: clinicaltrials.gov identifier: nct04381871. date of trial registration: 11 may 2020. full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. health. • experience in research -19) is caused by sars-cov2 and represents the causative agent of a potentially fatal disease caused global public concern. the disease spreads rapidly compared to the previous pandemics, which makes it more difficult to contain. due to this, there is an urgent need for fast diagnosis, preventive and therapeutic measures. patients infected with covid-19 showed higher leukocyte numbers, abnormal respiratory findings, and increased levels of plasma pro-inflammatory cytokines. main mechanism for ards (acute respiratory distress syndrome) is the cytokine storm, uncontrolled systemic inflammatory response resulting from the release of pro-inflammatory cytokines. the cytokine storm will trigger a violent attack by the immune system to the body, cause ards and multiple organ failure, and finally death in severe cases. current investigations, demonstrated that t cell numbers are negatively correlated to serum il-6, il-10 and tnf-α concentration, and proposed t cells as potential therapeutic trget. butyrate, is an epigenetic regulator via its capacity to act as a histone deacetylase (hdac) inhibitor. this may be directly relevant to the modulation of covid-19 infection. although data on the biological interactions of covid-19 with human physiology have still to be published, hdac inhibition is a common regulator of the effects of many viruses, including the influenza virus. the inhibition o fhdac1, as induced by butyrate, decreases influenza-driven pneumonia infections. gum arabic (ga) is a safe dietary fibres approved by fda and who. it is high molecular weight polysaccharide retrieved from acacia senegal and acacia seyal trees. ga fermentation produced short chain fatty acids mainly propionate and butyrate. gum arabic has anti-inflammatory effect which has been investigated in various diseases and conditions. scientific background: covid 19 pathogenesis: covid 19 coronavirus disease (covid-19) is caused by sars-cov2 and represents the causative agent of a potentially fatal disease that is of great global public health concern(1, 2). patients infected with covid-19 showed higher leukocyte numbers, abnormal respiratory findings, and increased levels of plasma pro-inflammatory cytokines(1-3). additionally, a value of 16.16 mg/l of blood c-reactive protein was noted which is above the normal range (0-10 mg/l) (2) . patients infected with covid-19 showed higher leukocyte numbers, abnormal respiratory findings, and increased levels of plasma pro-inflammatory cytokines. significantly high blood levels of cytokines and chemokines were noted in patients with covid-19 infection that included il1-β, il1ra, il7, il8, il9, il10, basic fgf2, gcsf, gmcsf, ifnγ, ip10, mcp1, mip1α, mip1β, pdgfb, tnfα, and vegfa(1) the latest report shows the number of cd4+ and cd8+ t cells in the peripheral blood of sars-cov-2-infected patients significantly is reduced, similarly, the acute phase response in patients with sars-cov is associated with severe decrease of cd4+ t and cd8+ t cells (3) . the report in lancet shows ards is the main death cause of covid-19. of the 41 sars-cov-2-infected patients admitted in the early stages of the outbreak, six died from ards(3). main mechanism for ards is the cytokine storm, the deadly uncontrolled systemic inflammatory response resulting from the release of large amounts of pro-inflammatory cytokines (3).the cytokine storm will trigger a violent attack by the immune system to the body, cause ards and multiple organ failure, and finally lead to death in severe cases of sars-cov-2 infection(1, 2) . ifn-i(ifn-α and ifn-β) has a protective effect on sars-cov and mers-cov infection, but the ifn-i pathway is inhibited in infected mice (4) . n number of total t cells, cd4+ and cd8+ t cells were dramatically reduced in covid-19 patients, especially among elderly patients (≥60 years of age) and in patients requiring intensive care unit (icu) (3) . statistical analysis demonstrated that t cell numbers are negatively correlated to serum il-6, il-10 and tnf-α concentration, potential therapeutic targets preventing cytokine storm. gum arabic fermentation increased the level of serum butyrate. butyrate, including in its nutraceutical form, sodium butyrate, is an epigenetic regulator via its capacity to act as a histone deacetylase (hdac) inhibitor. this may be directly relevant to the modulation of covid-19 infection (5) . although data on the biological interactions of covid-19 with human physiology have still to be published, hdac inhibition is a common regulator of the effects of many viruses, including the influenza virus. the inhibition of hdac1, as induced by butyrate, decreases influenza-driven pneumonia infections (5) gum arabic (ga) is a safe dietary fibres approved by fda and who (6) . it is high molecular weight non-starch polysaccharide retrieved from achaia senegal and achaia seyal trees (6, 7) . ga is mainly fermented by colonic bacteria instead of been digested among humans(8) and animals (6, 7) . ga fermentation produced short chain fatty acids mainly propionate and butyrate (6) (7) (8) . the latter discovered as physiological modifier for different body function like modulation of cell proliferation, apoptosis, regulation of angiogenesis and inflammation (9) . gum arabic antiinflammatory effect has been investigated in various diseases and conditions (10) (11) (12) . ga exerted local anti-inflammatory effects by modifying nuclear factor-κb (nf-κb) on the small intestine (13) . gum arabic anti-inflammatory effect has been investigated in clinical trials (10, 12) . an antiinflammatory effect of ga was demonstrated via the application of ga in drinking water given to rats with diabetes mellitus by a decrease of tnfα and il-1β and increase of il-10 (14). interestingly, bovo et al. investigated the effect of ga on the complement system, as arabinogalactans are reported to be complement system modulators. the authors showed a pro-inflammatory activity of ga by activation of the classical and alternative pathways of the complement system (15) . ga exerted local anti-inflammatory effects by modifying nuclear factor-κb (nf-κb) on the small intestine (12) . in addition, a reduction of oxidative stress was shown after ga supplementation of drinking water in the liver tissue of rats with type i diabetes (16 ) and oral ga supplementation in humans suffering from sickle cell anemia (17) . ga significantly increased oxidative burst/ros production of bovine and human granulocytes in a dose-dependent manner (18, 19) . similarly, arabinogalactan-protein (agp) of ga may have proinflammatory properties on certain parts of the immune system (18, 20) . from all the above the main pathogenesis of covid 19 is due to inflammatory process and cytokine storm. gum arabic is a prebiotic dietary fibers with proven anti-inflammatory properties and immunemodulatory agent. nowadays, most of research have carried out on corona-virus are in the primary stages and the exact mechanisms remains unknown, infection spread and deaths are increasing in daily bases, the urge for vaccine and protective elements against the immunological response of the body against the virus is needed. a novel corona virus from wuhan in central china, named 2019-ncov, has recently caused an epidemic of pneumonia in humans and posed a huge threat to global public health. to the date according to national ecdpc -ncov has led to more than 2744744 cases including 195387 deaths. which put heath system word wide in great challenge because no licensed vaccine and specific treatment. identification of natural products with direct antimicrobial effects or also immunomodulatory effects to boost the innate immune defense is a promising strategy to identify and characterize new treatment or prevention strategies. ga is a well-known traditional herbal medication from acacia senegal. gum arabic is prebiotic agent, with immune modulator properties. enhancing natural immunity and ameliorate the cytokines storm, will be of great benefits for covid 19 patients to overcome the disease. explore the role of gum arabic as immune modulator among covid 19 sudanese patients. the subjects, after stratification by age and sex, will randomly assigned to receive coded and indistinguishable gum arabic or placebo. randomization will be conducted by using a sequence of computer-generated random numbers by independent individual. each participating center will be assigned a special code generated by the computer. the randomization will be kept by the pi and a research assistant. the assessor for clinical outcomes would be blinded to the randomization status. the research staffs who perform the intervention would not know the assessment results. after the eligibility assessment by viral screening, laboratory and clinical assessments would be conducted at the baseline (after completion of informed consent), at first, second and 4th week gum arabic administration: ga in powder form, it is a 100% natural extract powder produced mechanically from the wildly grown acacia senegal tree with a particle size less than 210 μm. the daily dose is 45 gram per day. it will be given in one sachet to be consumed in the early morning dissolved in 200 ml of water. the ga will be provided to the participants weekly for four weeks (7 sachets for each visit). standardized questionnaire and check list will be used to collect data about patients' physical examination, weight, height, severity of the symptoms and any side effects. gum arabic will be purchased from nature gum company, khartoum sudan. placebo will be pectin one gram per day. it will be given in one sachet to be consumed in the early morning dissolved in 200 ml of water for 4 weeks. the procedures for screening will be performed within one week before dosing, except where otherwise stated, and included the following: iii. elisa for cytokines study protocols: each patient will receive daily dose the patients will be followed every week and the following investigation will be done during the visit for follow up: cbc, and urine analysis. lft and rft will be done weekly blood samples will be collected by certified nurse and will be used solely for the research purposes and will be destructed after completing the project. data will be collected and coded and entered in excel sheet. spss .24 and graph prism will be used. paired t test will be used to determine statistical significance between baseline and post treatment results. p equal to or less than .05 will consider statistically significant. data will be presented as means (±sd). • references: • annexes: -ethics consideration -‫البحث‬ ‫بروتوكول‬ molecular immune pathogenesis and diagnosis of covid-19 the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak reduction and functional exhaustion of t cells in patients with coronavirus disease regulation of interferon production as a potential strategy for covid-19 treatment psychological stress and covid-19: interactions with gut microbiome and circadian rhythm in driving symptom severity the regulatory and scientific approach to defining gum arabic (acacia senegal and acacia seyal) as a dietary fibre applications of natural polymer gum arabic: a review butyric acid from the diet: actions at the level of gene expression effect of gum arabic (acacia senegal) on c gum arabic reduces c-reactive protein in chronic kidney disease patients without affecting urea or indoxyl sulfate levels gum arabic fibers decreased inflammatory markers and disease severity score among rheumatoid arthritis patients, phase ii trial modulation of rat intestinal nuclear factor nf-κb by gum arabic. digestive diseases and sciences gum acacia improves renal function and ameliorates systemic inflammation, oxidative and nitrosative stress in streptozotocin-induced diabetes in rats with adenine-induced chronic kidney disease modulating effects of arabinogalactans from plant gum exudates on human complement system protective effect of long term administration of gum arabic on oxidative stress in hepatic tissue of diabetic rats gum arabic as novel anti-oxidant agent in sickle cell anemia, phase ii trial protective effect of arabic gum against acetaminopheninduced hepatotoxicity in mice gum acacia improves renal function and ameliorates systemic inflammation, oxidative and nitrosative stress in streptozotocin-induced diabetes in rats with adenine-induced chronic kidney disease antimicrobial and immunomodulatory effect of gum arabic on human and bovine granulocytes against staphylococcus aureus and escherichia coli key: cord-350224-dt3li3bk authors: ye, qingsong; wang, hua; xia, xia; zhou, chenliang; liu, zhiming; xia, zun-en; zhang, zhan; zhao, yang; yehenala, jun; wang, si; zhou, gangqiao; hu, ke; wu, bin; wu, chu-tse; wang, songling; he, yan title: safety and efficacy assessment of allogeneic human dental pulp stem cells to treat patients with severe covid-19: structured summary of a study protocol for a randomized controlled trial (phase i / ii) date: 2020-06-12 journal: trials doi: 10.1186/s13063-020-04380-5 sha: doc_id: 350224 cord_uid: dt3li3bk objectives: to assess the safety and therapeutic effects of allogeneic human dental pulp stem cells (dpscs) in treating severe pneumonia caused by covid-19. trial design: this is a single centre, two arm ratio 1:1, triple blinded, randomized, placebo-controlled, parallel group, clinical trial. participants: 1. adults aged 18-65 years; 2. voluntarily participate in this clinical trial and sign the “informed consent form” or have consent from a legal representative. 3. diagnosed with severe pneumonia of covid-19: nucleic acid test sars-cov-2 positive; respiratory distress (respiratory rate > 30 times / min); hypoxia (resting oxygen saturation < 93% or arterial partial pressure of oxygen / oxygen concentration < 300 mmhg). 4. covid-19 featured lung lesions in chest x-ray image. 1. patients have received other experimental treatment for covid-19 within the last 30 days; 2. patients have severe liver condition (e.g., child pugh score >=c or ast> 5 times of the upper limit); 3. patients with severe renal insufficiency (estimated glomerular filtration rate <=30ml / min/1.73 m(2)) or patients receiving continuous renal replacement therapy, hemodialysis, peritoneal dialysis; 4. patients who are co-infected with hiv, hepatitis b, tuberculosis, influenza virus, adenovirus or other respiratory infection viruses; 5. female patients who have no sexual protection in the last 30 days prior to the screening assessment; 6. pregnant or lactating women or women using estrogen contraception; 7. patients who are planning to become pregnant during the study period or within 6 months after the end of the study period; 8. other conditions that the researchers consider not suitable for participating in this clinical trial. intervention and comparator: there will be two study groups: experimental and control. both will receive all necessary routine treatment for covid-19. the experimental group will receive an intravenous injection of dental pulp stem cells suspension (3.0x10(7) human dpscs in 30ml saline solution) on day 1, 4 and 7; the control group will receive an equal amount of saline (placebo) on the same days. clinical and laboratory observations will be performed for analysis during a period of 28 days for each case since the commencement of the study. main outcomes: 1. primary outcome the primary outcome is time to clinical improvement (ttci). by definition, ttci is the time (days) it takes to downgrade two levels from the following six ordered grades [(grade 1) discharge to (grade 6) death] in the clinical state of admission to the start of study treatments (hdpscs or placebo). six grades of ordered variables: 2. secondary outcomes 2.1 vital signs: heart rate, blood pressure (systolic blood pressure, diastolic blood pressure). during the screening period, hospitalization every day (additional time points of d1, d4, d7 30min before injection, 2h ± 30min, 24h ± 30min after the injection) and follow-up period d90 ± 3 days. 2.2 laboratory examinations: during the screening period, 30 minutes before d1, d4, d7 infusion, 2h ± 30min, 24h ± 30min after the end of infusion, d10, d14, d28 during hospitalization or discharge day and follow-up period d90 ± 3 days. 2.3 blood routine: white blood cells, neutrophils, lymphocytes, monocytes, eosinophils, basophils, neutrophils, lymphocytes, monocytes, eosinophils acidic granulocyte count, basophil count, red blood cell, hemoglobin, hematocrit, average volume of red blood cells, average red blood cell hb content, average red blood cell hb concentration, rdw standard deviation, rdw coefficient of variation, platelet count, platelet specific platelet average volume, platelet distribution width,% of large platelets; 2.4 liver and kidney function tests: alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, γ-glutamyl transferase, prealbumin, total protein, albumin, globulin, white / globule ratio , total bilirubin, direct bilirubin, cholinesterase, urea, creatinine, total carbon dioxide, uric acid glucose, potassium, sodium, chlorine, calcium, corrected calcium, magnesium, phosphorus, calcium and phosphorus product, anion gap, penetration pressure, total cholesterol, triacylglycerol, high density lipoprotein cholesterol, low density lipoprotein cholesterol, lipoprotein a, creatine kinase, lactate dehydrogenase, estimated glomerular filtration rate. 2.5 inflammation indicators: hypersensitive c-reactive protein, serum amyloid (saa); 2.6 infectious disease testing: hepatitis b (hbsag, hbsab, hbeag, hbeab, hbcab), hepatitis c (anti-hcv), aids (hivcombin), syphilis (anti-tp), cytomegalovirus cmv-igm, cytomegalovirus cmv-igg; only during the screening period and follow-up period d90 ± 3. 2.7 immunological testing: collect peripheral blood to detect the phenotype of t lymphocyte, b lymphocyte, natural killer cell, macrophage and neutrophil by using flow cytometry. collect peripheral blood to detect the gene profile of mononuclear cells by using single-cell analyses. collect peripheral blood serum to detect various immunoglobulin changes: iga, igg, igm, total ige; collect peripheral blood serum to explore the changes of cytokines, th1 cytokines (il-1 β, il-2, tnf-a, itn-γ), th2 cytokines (il-4, il-6, il -10). 2.8 pregnancy test: blood β-hcg, female subjects before menopause are examined during the screening period and follow-up period d90 ± 3. 2.9 urine routine: color, clarity, urine sugar, bilirubin, ketone bodies, specific gravity, ph, urobilinogen, nitrite, protein, occult blood, leukocyte enzymes, red blood cells, white blood cells, epithelial cells, non-squamous epithelial cells , transparent cast, pathological cast, crystal, fungus; 2.10 stool routine: color, traits, white blood cells, red blood cells, fat globules, eggs of parasites, fungi, occult blood (chemical method), occult blood (immune method), transferrin (2h ± 30min after the injection and not detected after discharge). randomization: block randomization method will be applied by computer to allocate the participants into experimental and control groups. the random ratio is 1:1. blinding (masking): participants, outcomes assessors and investigators (including personnel in laboratory and imaging department who issue the sample report or image observations) will be blinded. injections of cell suspension and saline will be coded in accordance with the patient’s randomisation group. the blind strategy is kept by an investigator who does not deliver the medical care or assess primary outcome results. numbers to be randomized (sample size): twenty participants will be randomized to the experimental and control groups (10 per group). trial status: protocol version number, hdpsc-covid-2019-02-2020 version 2.0, march 13, 2020. patients screening commenced on 16(th) april and an estimated date of the recruitment of the final participants will be around end of july. . trial registration: registration: world health organization trial registry: chictr2000031319; march 27,2020. clinicaltrials.gov identifier: nct04336254; april 7, 2020 other study id numbers: hdpsc-covid-2019-02-2020 full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. 1. patients have received other experimental treatment for covid-19 within the last 30 days; 2. patients have severe liver condition (e.g., child pugh score >=c or ast> 5 times of the upper limit); 3. patients with severe renal insufficiency (estimated glomerular filtration rate <=30ml / min/1.73 m 2 ) or patients receiving continuous renal replacement therapy, hemodialysis, peritoneal dialysis; 4. patients who are co-infected with hiv, hepatitis b, tuberculosis, influenza virus, adenovirus or other respiratory infection viruses; 5. female patients who have no sexual protection in the last 30 days prior to the screening assessment; 6. pregnant or lactating women or women using estrogen contraception; 7. patients who are planning to become pregnant during the study period or within 6 months after the end of the study period; 8. other conditions that the researchers consider not suitable for participating in this clinical trial. intervention and comparator: there will be two study groups: experimental and control. both will receive all necessary routine treatment for covid-19. the experimental group will receive an intravenous injection of dental pulp stem cells suspension (3.0x10 7 human dpscs in 30ml saline solution) on day 1, 4 and 7; the control group will receive an equal amount of saline (placebo) on the same days. clinical and laboratory observations will be performed for analysis during a period of 28 days for each case since the commencement of the study. main outcomes: 1. primary outcome the primary outcome is time to clinical improvement (ttci). by definition, ttci is the time (days) it takes to downgrade two levels from the following six ordered grades [(grade 1) discharge to (grade 6) death] in the clinical state of admission to the start of study treatments (hdpscs or placebo). six grades of ordered variables: 2. secondary outcomes 2.1 vital signs: heart rate, blood pressure (systolic blood pressure, diastolic blood pressure). during the screening period, hospitalization every day (additional time points of d1, d4, d7 30min before injection, 2h ± 30min, 24h ± 30min after the injection) and follow-up period d90 ± 3 days. 2.2 laboratory examinations: during the screening period, 30 minutes before d1, d4, d7 infusion, 2h ± 30min, 24h ± 30min after the end of infusion, d10, d14, d28 during hospitalization or discharge day and follow-up period d90 ± 3 days. 2.3 blood routine: white blood cells, neutrophils, lymphocytes, monocytes, eosinophils, basophils, neutrophils, lymphocytes, monocytes, eosinophils acidic granulocyte count, basophil count, red blood cell, hemoglobin, hematocrit, average volume of red blood cells, average red blood cell hb content, average red blood cell hb concentration, rdw standard deviation, rdw coefficient of variation, platelet count, platelet specific platelet average volume, platelet distribution width,% of large platelets; 2.4 liver and kidney function tests: alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, γ-glutamyl transferase, prealbumin, total protein, albumin, globulin, white / globule ratio , total bilirubin, direct bilirubin, cholinesterase, urea, creatinine, total carbon dioxide, uric acid glucose, potassium, sodium, chlorine, (continued on next page) grade 1: discharged of patient; grade 2: hospitalized without oxygen supplement; grade 3: hospitalized, oxygen supplement is required, but niv / hfnc is not required; grade 4: hospitalized in intensive care unit, and niv / hfnc treatment is required; grade 5: hospitalized in intensive care unit, requiring ecmo and/or imv; grade 6: death. collect peripheral blood to detect the gene profile of mononuclear cells by using single-cell analyses. collect peripheral blood serum to detect various immunoglobulin changes: iga, igg, igm, total ige; collect peripheral blood serum to explore the changes of cytokines, th1 cytokines (il-1 β, il-2, tnf-a, itn-γ), th2 cytokines (il-4, il-6, il -10). 2.8 pregnancy test: blood β-hcg, female subjects before menopause are examined during the screening period and follow-up period d90 ± 3. 2.9 urine routine: color, clarity, urine sugar, bilirubin, ketone bodies, specific gravity, ph, urobilinogen, nitrite, protein, occult blood, leukocyte enzymes, red blood cells, white blood cells, epithelial cells, non-squamous epithelial cells , transparent cast, pathological cast, crystal, fungus; 2.10 stool routine: color, traits, white blood cells, red blood cells, fat globules, eggs of parasites, fungi, occult blood (chemical method), occult blood (immune method), transferrin (2h ± 30min after the injection and not detected after discharge). randomization: block randomization method will be applied by computer to allocate the participants into experimental and control groups. the random ratio is 1:1. blinding (masking): participants, outcomes assessors and investigators (including personnel in laboratory and imaging department who issue the sample report or image observations) will be blinded. injections of cell suspension and saline will be coded in accordance with the patient's randomisation group. the blind strategy is kept by an investigator who does not deliver the medical care or assess primary outcome results. numbers to be randomized (sample size): twenty participants will be randomized to the experimental and control groups (10 per group). full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. keywords: covid-19; randomised controlled trial; protocol; human dental pulp stem cells; dental stem cell banking beijing institute of radiation medicine, beijing 100850, china. 3 beijing sh biotechnology co., ltd publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors acknowledge the chu-tse wu foundation for science & technology development for sponsoring this study. beijing sh biotechnology co., ltd. and utooth biological technology co., ltd. are acknowledged for providing the dpscs for this study. we would like to extend our appreciation to our collaborators and the nurses, clinicians and lab technicians at the renmin hospital and center of regenerative medicine, wuhan university. supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04380-5.additional file 1. full study protocol.authors' contributions qy, zw and slw conceived the research idea; qy, hw, xx, yh and gz designed the study protocol and developed the research plan; cz and qy obtained the ethics approval; qy and zl coordinated the tasks among different investigators; cz, zz, zl and qy yz and kh recruited the participants and collected data. jy and sw will deliver the treatment to the participants; zx and bw will be the quality controller for the dpscs intervention; xx manages the blind strategy. qy and yh will analyse the data and interpret the result. yh drafted the manuscript; qy, hw, xx revised and finalised the manuscript; qy, zw and slw proofread the manuscript prior to submission. the author(s) read and approved the final manuscript. the trial has been financially funded by the chu-tse wu foundation for science & technology development, a non-profit organization. the design of the study, as well as the collection, analysis and interpretation of data will not be influenced by the funding body. the writing of the protocol and the decision to submit for publication are compiled independent from the funding body. the data will be stored in a repository managed by a third party called clinflash, a professional data management service for clinical studies (weblink: https://edc.clinflash.net/shbio). member investigators of the trial will have access to the final trial dataset, depending on level of need-to-know. the study was approved by the committee of ethics for clinical research, renmin hospital of wuhan university, on 03/14/2020. the ethical approval number is wdry2020-k106. recruitment has been ongoing by the investigators. once informed consent is signed off by both parties, the investigator and participating patient/ legal representative, the participant will be enrolled in the study. the consent form and materials are available from the corresponding author on request. the authors declare that they have no competing interests.author details 1 key: cord-310169-yn7pu9i8 authors: marietta, marco; vandelli, paola; mighali, pasquale; vicini, roberto; coluccio, valeria; d’amico, roberto title: randomised controlled trial comparing efficacy and safety of high versus low low-molecular weight heparin dosages in hospitalized patients with severe covid-19 pneumonia and coagulopathy not requiring invasive mechanical ventilation (covid-19 hd): a structured summary of a study protocol date: 2020-06-26 journal: trials doi: 10.1186/s13063-020-04475-z sha: doc_id: 310169 cord_uid: yn7pu9i8 objectives: a. 1. death. 2. acute myocardial infarction [ami]. 3. objectively confirmed, symptomatic arterial or venous thromboembolism [te]. 4. a. continuous positive airway pressure (cpap) or non-invasive ventilation (niv) or b. imv in patients who at randomisation were receiving standard oxygen therapy. 5. imv in patients who at randomisation were receiving non-invasive mechanical ventilation. b. similar in terms of major bleeding risk. trial design: multicentre, randomised controlled, superiority, open label, parallel group, two arms (1:1 ratio), in-hospital study. participants: inpatients will be recruited from 7 italian academic and non-academic internal medicine units, 2 infectious disease units and 1 respiratory disease unit. inclusion criteria (all required): 1. age > 18 and < 80 years. 2. positive sars-cov-2 diagnostic (on pharyngeal swab of deep airways material). 3. a. respiratory rate ≥25 breaths /min. b. arterial oxygen saturation≤93% at rest on ambient air. c. pao2/fio2 ≤300 mmhg. 4. a. d-dimer >4 times the upper level of normal reference range. b. sepsis-induced coagulopathy (sic) score >4. 5. no need of imv. exclusion criteria: 1. age <18 and >80 years. 2. imv. 3. thrombocytopenia (platelet count < 80.000 mm3). 4. coagulopathy: inr >1.5, aptt ratio > 1.4. 5. impaired renal function (egfr calculated by ckd-epi creatinine equation < 30 ml/min). 6. known hypersensitivity to enoxaparin. 7. history of heparin induced thrombocytopenia. 8. presence of an active bleeding or a pathology susceptible of bleeding in presence of anticoagulation (e.g. recent haemorrhagic stroke, peptic ulcer, malignant cancer at high risk of haemorrhage, recent neurosurgery or ophthalmic surgery, vascular aneurysms, arteriovenous malformations). 9. concomitant anticoagulant treatment for other indications (e.g. atrial fibrillation, venous thromboembolism, prosthetic heart valves). 10. concomitant double antiplatelet therapy. 11. administration of therapeutic doses of lmwh, fondaparinux, or unfractionated heparin (ufh) for more than 72 hours before randomization; prophylactic doses are allowed. 12. pregnancy or breastfeeding or positive pregnancy test. 13. presence of other severe diseases impairing life expectancy (e.g. patients are not expected to survive 28 days given their pre-existing medical condition). 14. lack or withdrawal of informed consent. intervention and comparator: control group (low-dose lmwh): patients in this group will be administered enoxaparin (inhixa®) at standard prophylactic dose (i.e., 4000 ui subcutaneously once day). intervention group (high-dose lmwh): patients in this group will be administered enoxaparin (inhixa®) at dose of 70 iu/kg every 12 hours, as reported in the following table. this dose is commonly used in italy when a bridging strategy is required for the management of surgery or invasive procedures in patients taking anti-vitamin k oral anticoagulants the treatment with enoxaparin will be initiated soon after randomization (maximum allowed starting time 12h after randomization). the treatment will be administered every 12 hours in the intervention group and every 24 hours in the control group. treatments will be administered in the two arms until hospital discharge or the primary outcomes detailed below occur. main outcomes: primary efficacy endpoint: 1. death. 2. acute myocardial infarction [ami]. 3. objectively confirmed, symptomatic arterial or venous thromboembolism [te]. 4. a. continuous positive airway pressure (cpap) or non-invasive ventilation (niv) or b. imv in patients who at randomisation were in standard oxygen therapy by delivery interfaces. 5. need for imv, in patients who at randomisation were in cpap or niv. time to the occurrence of each of these events will be recorded. clinical worsening will be analysed as a binary outcome as well as a time-to-event one. secondary efficacy endpoints: : 1. death. 2. acute myocardial infarction [ami]. 3. objectively confirmed, symptomatic arterial or venous thromboembolism [te]. 4. a. continuous positive airway pressure (cpap) or non-invasive ventilation (niv) or b. imv in patients who at randomisation were in standard oxygen therapy by delivery interfaces. 5. need for imv in patients who at randomisation were in cpap or niv. 6. o d-dimer level; o plasma fibrinogen levels; o mean platelet volume; o lymphocyte/neutrophil ratio; o il-6 plasma levels. mortality at 30 days: information about patients’ status will be sought in those who are discharged before 30 days on day 30 from randomisation. time to the occurrence of each of these events will be recorded. each of these events will be analysed as a binary outcome and as a time-to-event one. primary safety endpoint: decrease in haemoglobin of 2 g/dl or more; transfusion of 2 or more units of packed red blood cells; bleeding that occurs in at least one of the following critical sites [intracranial, intraspinal, intraocular (within the corpus of the eye; thus, a conjunctival bleed is not an intraocular bleed), pericardial, intra-articular, intramuscular with compartment syndrome, or retroperitoneal]; bleeding that is fatal (defined as a bleeding event that was the primary cause of death or contributed directly to death); bleeding that necessitates surgical intervention. time to the occurrence of each of these events will be recorded. each of these events will be analysed as a binary outcome and as a time-to-event one. secondary safety endpoint: 1. any bleeding compromising hemodynamic. 2. spontaneous hematoma larger than 25 cm2, or 100 cm2 if there was a traumatic cause. 3. intramuscular hematoma documented by ultrasonography. 4. epistaxis or gingival bleeding requiring tamponade or other medical intervention. 5. bleeding from venipuncture for >5 minutes. 6. haematuria that was macroscopic and was spontaneous or lasted for more than 24 hours after invasive procedures. 7. haemoptysis, hematemesis or spontaneous rectal bleeding requiring endoscopy or other medical intervention. 8. any other bleeding requiring temporary cessation of a study drug. time to the occurrence of each of these events will be recorded. each of these events will be analysed as a binary outcome and as a time-to-event one. randomisation: randomisation (with a 1:1 randomisation ratio) will be centrally performed by using a secure, web-based system, which will be developed by the methodological and statistical unit at the azienda ospedaliero-universitaria of modena. randomisation stratified by 4 factors: 1) gender (m/f); 2) age (<75/≥75 years); 3) bmi (<30/≥30); 4) comorbidities (0-1/>2) with random variable block sizes will be generated by stata software. the web-based system will guarantee the allocation concealment. blinding (masking) the study is conceived as open-label: patients and all health-care personnel involved in the study will be aware of the assigned group. numbers to be randomised (sample size): the target sample size is based on the hypothesis that lmwh administered at high doses versus low doses will significantly reduce the risk of clinical worsening. the overall sample size in this study is expected to be 300 with 150 in the low-dose lmwh control group and 150 in the high-dose lmwh intervention group, recruited over 10-11 months. assuming an alpha of 5% (two tailed) and a percentage of patients who experience clinical worsening in the control group being between 25% and 30%, the study will have 80% power to detect at least 50% relative reduction in the risk of death between low and high doses of heparin. trial status: protocol version 1.2 of 11/05/2020. recruitment start (expected): 08/06/2020 recruitment finish (expected): 30/04/2021 trial registration eudract 2020-001972-13, registered on april 17th, 2020 full protocol the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. trial design: multicentre, randomised controlled, superiority, open label, parallel group, two arms (1:1 ratio), in-hospital study. participants: inpatients will be recruited from 7 italian academic and non-academic internal medicine units, 2 infectious disease units and 1 respiratory disease unit. inclusion criteria (all required): 1. age > 18 and < 80 years 2. positive sars-cov-2 diagnostic (on pharyngeal swab of deep airways material) 3. severe pneumonia defined by the presence of at least one of the following criteria: a. respiratory rate ≥25 breaths /min b. arterial oxygen saturation≤93% at rest on ambient air c. pao2/fio2 ≤300 mmhg 4. coagulopathy, defined by the presence of at least one of the following criteria: a. d-dimer >4 times the upper level of normal reference range b. sepsis-induced coagulopathy (sic) score >4 exclusion criteria: 1. age <18 and >80 years 2. imv 3. thrombocytopenia (platelet count < 80.000 mm3) 4. coagulopathy: inr >1.5, aptt ratio > 1.4 5. impaired renal function (egfr calculated by ckd-epi creatinine equation < 30 ml/min) 6. known hypersensitivity to enoxaparin 7. history of heparin induced thrombocytopenia 8. presence of an active bleeding or a pathology susceptible of bleeding in presence of anticoagulation (e.g. recent haemorrhagic stroke, peptic ulcer, malignant cancer at high risk of haemorrhage, recent neurosurgery or ophthalmic surgery, vascular aneurysms, arteriovenous malformations) 9. concomitant anticoagulant treatment for other indications (e.g. atrial fibrillation, venous thromboembolism, prosthetic heart valves) 10. concomitant double antiplatelet therapy 11. administration of therapeutic doses of lmwh, fondaparinux, or unfractionated heparin (ufh) for more than 72 hours before randomization; prophylactic doses are allowed 12. pregnancy or breastfeeding or positive pregnancy test 13. presence of other severe diseases impairing life expectancy (e.g. patients are not expected to survive 28 days given their pre-existing medical condition) 14. lack or withdrawal of informed consent intervention and comparator: control group (low-dose lmwh): patients in this group will be administered enoxaparin (inhixa®) at standard prophylactic dose (i.e., 4000 ui subcutaneously once day). intervention group (high-dose lmwh): patients in this group will be administered enoxaparin (inhixa®) at dose of 70 iu/kg every 12 hours, as reported in the following table. this dose is commonly used in italy when a bridging (continued on next page) strategy is required for the management of surgery or invasive procedures in patients taking anti-vitamin k oral anticoagulants the treatment with enoxaparin will be initiated soon after randomization (maximum allowed starting time 12h after randomization). the treatment will be administered every 12 hours in the intervention group and every 24 hours in the control group. treatments will be administered in the two arms until hospital discharge or the primary outcomes detailed below occur. main outcomes: primary efficacy endpoint: clinical worsening, defined as the occurrence of at least one of the following events, whichever comes first: a. continuous positive airway pressure (cpap) or non-invasive ventilation (niv) or b. imv in patients who at randomisation were in standard oxygen therapy by delivery interfaces 5. need for imv, in patients who at randomisation were in cpap or niv time to the occurrence of each of these events will be recorded. clinical worsening will be analysed as a binary outcome as well as a time-to-event one. secondary efficacy endpoints: any of the following events occurring within the hospital stay mortality at 30 days: information about patients' status will be sought in those who are discharged before 30 days on day 30 from randomisation. time to the occurrence of each of these events will be recorded. each of these events will be analysed as a binary outcome and as a time-to-event one. primary safety endpoint: major bleeding, defined as an acute clinically overt bleeding associated with one or more of the following: -decrease in haemoglobin of 2 g/dl or more; -transfusion of 2 or more units of packed red blood cells; -bleeding that occurs in at least one of the following critical sites [intracranial, intraspinal, intraocular (within the corpus of the eye; thus, a conjunctival bleed is not an intraocular bleed), pericardial, intra-articular, intramuscular with compartment syndrome, or retroperitoneal]; -bleeding that is fatal (defined as a bleeding event that was the primary cause of death or contributed directly to death); -bleeding that necessitates surgical intervention time to the occurrence of each of these events will be recorded. each of these events will be analysed as a binary outcome and as a time-to-event one. secondary safety endpoint: clinically relevant non-major bleeding, defined as an acute clinically overt bleeding that does not meet the criteria for major and consists of: 1. any bleeding compromising hemodynamic 2. spontaneous hematoma larger than 25 cm2, or 100 cm2 if there was a traumatic cause 3. intramuscular hematoma documented by ultrasonography 4. epistaxis or gingival bleeding requiring tamponade or other medical intervention 5. bleeding from venipuncture for >5 minutes 6. haematuria that was macroscopic and was spontaneous or lasted for more than 24 hours after invasive procedures 7. haemoptysis, hematemesis or spontaneous rectal bleeding requiring endoscopy or other medical intervention 8. any other bleeding requiring temporary cessation of a study drug. time to the occurrence of each of these events will be recorded. each of these events will be analysed as a binary outcome and as a time-to-event one. randomisation: randomisation (with a 1:1 randomisation ratio) will be centrally performed by using a secure, web-based system, which will be developed by the methodological and statistical unit at the azienda ospedaliero-universitaria of modena. randomisation stratified by 4 factors: 1) gender (m/f); 2) age (<75/≥75 years); 3) bmi (<30/≥30); 4) comorbidities (0-1/>2) with random variable block sizes will be generated by stata software. the web-based system will guarantee the allocation concealment. blinding (masking) the study is conceived as open-label: patients and all health-care personnel involved in the study will be aware of the assigned group. numbers to be randomised (sample size): the target sample size is based on the hypothesis that lmwh administered at high doses versus low doses will significantly reduce the risk of clinical worsening. the overall sample size in this study is expected to be 300 with 150 in the low-dose lmwh control group and 150 in the high-dose lmwh intervention group, recruited over 10-11 months. assuming an alpha of 5% (two tailed) and a percentage of patients who experience clinical worsening in the control group being between 25% and 30%, the study will have 80% power to detect at least 50% relative reduction in the risk of death between low and high (continued on next page) doses of heparin. trial status: protocol version 1.2 of 11/05/2020. recruitment start (expected): 08/06/2020 recruitment finish (expected): 30/04/2021 trial registration eudract 2020-001972-13, registered on april 17th, 2020 full protocol the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. keywords: covid-19, randomised controlled trial, protocol, low-molecular weight heparin, enoxaparin, pneumonia, coagulopathy supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04475-z. additional file 1. full protocol. unità operativa cardiologia riabilitativa, dipartimento emergenza urgenza, azienda unità sanitaria locale di piacenza medicina interna d'urgenza e area critica, azienda ospedaliero-universitaria di modena infectious disease unit, onco-hematology department, hospital of piacenza internal medicine unit, medical department, hospital of piacenza unità operativa pronto soccorso, obi e medicina d'urgenza, dipartimento emergenza urgenza, azienda unità sanitaria locale di piacenza infectious diseases clinics infectious diseases clinics unità operativa medicina interna val d'arda, dipartimento delle medicine, azienda unità sanitaria locale di piacenza medicina interna d'urgenza e area critica, dipartimento di medicina interna generale, d'urgenza e post-acuzie medicina interna d'urgenza e area critica, azienda ospedaliero-universitaria di unità operativa medicina d'urgenza pronto soccorso obi acknowledgements *covid-19 hd study group: authors' contributions mm and rda conceived and designed the study; rv developed the ecrf; pm submitted the study to the ethical committee; vc wrote the full protocol; pv coordinated the project group. all the authors contributed to develop the study protocol. the author(s) read and approved the final manuscript. funded by azienda ospedaliero-universitaria di modena, italy. the funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. the study data will be collected during the entire study period in a dedicated electronic case report form (ecrf) provided by the steering committee (sc). data will be collected and stored on the hospital server, which will be protected by password to prevent unintentional modification or deletion.ethics approval and consent to participate approved by comitato etico dell'istituto nazionale per le malattie infettive "lazzaro spallanzani", rome, italy, on 21/05/2020; reference number of the ethical approval judgement 124/2020. the authors certify that this trial has received ethical approval from the appropriate ethical committee as described above. the investigator at each centre will ensure that the subject is given full and adequate oral and written information about the nature, purpose, possible risks and benefits of the study. subjects must also be notified that they are free to discontinue from the study at any time. the subject's signed and dated informed consent must be obtained prior to conduct any procedure specific for the study. the original signed written informed consent form must be stored, and a copy must be given to the patient. not applicable. the authors declare that they have no competing interests. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-282474-74273qgk authors: roehrig, stefan; ait hssain, ali; shallik, nabil al hamid; elsaid, ingi mohamed a.; mustafa, salma faisal; smain, osama a. m.; molokhia, ashraf abdulla; lance, marcus d. title: flow controlled ventilation in acute respiratory distress syndrome associated with covid-19: a structured summary of a study protocol for a randomised controlled trial date: 2020-09-11 journal: trials doi: 10.1186/s13063-020-04708-1 sha: doc_id: 282474 cord_uid: 74273qgk objectives: this study aims to demonstrate the positive effects on oxygenation of flow-controlled ventilation compared to conventionally ventilated patients in patients suffering from acute respiratory distress syndrome (ards) associated with covid-19.we define ards according to the “berlin” definition integrating the oxygenation index (p/f ratio), the level of positive end expiratory pressure (peep), radiological and clinical findings. trial design: this is a prospective, randomized (1:1 ratio), parallel group feasibility study in adult patients with proven covid-19 associated ards. participants: all adult patients admitted to the icu of hamad medical corporation facilities in qatar because of covid-19 infection who develop moderate to severe ards are eligible. the inclusion criteria are above 18 years of age, proven covid-19 infection, respiratory failure necessitating intubation and mechanical ventilation, ards with a p/f ratio of at least 200mmhg or less and a minimum peep 5cmh2o, bmi less 30 kg/ m2. the following exclusion criteria: no written consent, chronic respiratory disease, acute or chronic cardiovascular disease, pregnancy or need for special therapy (prone position and/or extracorporeal membrane oxygenation). intervention and comparator: after randomisation, the group a patients will be ventilated with the test-device for 48 hours. the settings will be started with the pre-existing-peep. the upper pressure will be determined to achieve a tidal volume of 6 ml/kg lean body mass, while the respiratory rate will be set to maintain an arterial ph above 7.2. in group b, the ventilator settings will be adjusted by the attending icu team in accordance with lung-protective ventilation strategy. all other treatment will be unchanged and according to our local policies/guidelines. main outcomes: the primary end point is pao2. as this is a dynamic parameter, we will record it every 6-8 hours and analyse it sequentially. randomisation: the study team screens the ventilated patients who fulfil the inclusion criteria and randomise using a 1:1 allocation ratio after consenting using a closed envelope method. the latter were prepared and sealed in advance by an independent person. blinding (masking): due to the technical nature of the study (use of a specific ventilator) blinding is only possible for the data-analysts and the patients. numbers to be randomised (sample size): the sample size calculation based on the assumption of an effect size (change in pao2) of 1.5 sds in the primary endpoint (pao2), an intended power of 80%, an alpha error of 5% and an equal sample ratio results in n=7 patients needed to treat. however, to compensate for dropouts we will include 10 patients in each group, which means in total 20 patients. trial status: the local registration number is mrc-05-018 with the protocol version number 3. the date of approval is 14(th) april 2020. recruitment began 28th may 2020 and is expected to end in september 2020. trial registration: the protocol was registered before starting subject recruitment under the title: “flow controlled ventilation in ards associated with covid-19” in clinicaltrials.org with the registration number: nct04399317. registered on 22 may 2020. full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. the pandemic of a newly upcoming viral disease which is associated with covid-19 puts the whole world's health system under pressure. patients suffering from this disease mainly develop respiratory symptoms, which can lead to severe acute respiratory distress syndrome (ards) necessitating icu, admission in 10-20% of the cases admitted to hospital. in addition to these symptoms, patients show lymphopenia, cardiac symptoms and altered coagulation profiles. although those patients are treated in the icu the mortality is up to 20% due to multiorgan failure [1, 2] . the aim of this study is to show non-inferiority of flow-controlled ventilation [5, 6, 7] compared to standard (lung protective ventilation) [3, 4] . after admission to the icu, the patients will receive information about the study and informed consent will be taken. upon reaching the criteria for moderate to severe ards (p/f ratio below 200 mmhg and peep above 5 cmh2o) the patients will be randomized. in the treatment group (group a) the ultra-thin ventilation tube will be placed through the existing tube. then flow-controlled ventilation will be applied for 48 hours. in the other group (group b) ventilation will be performed according to the lung protective strategy. all other treatment will be unchanged. data-collection will be started 1 hour after initiation of the study. primary end point is pao2. dr the pandemic of a newly upcoming viral disease which is associated with covid-19 puts the whole world's health system under pressure. patients suffering from this disease mainly develop respiratory symptoms, which can lead to severe acute respiratory distress syndrome (ards) necessitating icu admission in 10-20% of the cases admitted to hospital (scc-guideline). in addition to these symptoms, patients show lymphopenia, cardiac symptoms and altered coagulation profiles. although those patients are treated in the icu the mortality there is up to 20% due to multiorgan failure [1, 2] . currently, there is no proven therapeutic strategy next to symptomatic treatment. although the severely ill patients will need intubation and invasive ventilation according to ards treatment strategies including low tidal volumes and low end-expiratory pressures, not all patients recover their pulmonary function [3, 4] . flow control ventilation (fcv) is a recently developed ventilation strategy which allows to keep the intrapulmonary pressures low while achieving optimal gas exchange [5] . it had been proven in animal models to improve pulmonary function and oxygenation [6] and in cases with ards [7] . flow controlled ventilation mode is a unique ventilation technique in which inspiration as well as expiration are controlled i.e. actively performed. this is achieved by generating a continuous flow into the patient's lungs during inspiration or a continuous (negative) flow, sucking gasses out of the patient's lungs. the continuous flow without ventilation pauses, results in linear increases and decreases in intratracheal pressures [ figure 1 ]. as a result, the mean airway pressure will be higher compared to conventional large bore volume controlled ventilation or pressure controlled ventilation (pcv). therefore, the bronchiole and alveoli will be kept open during ventilation facilitating oxygen uptake to the blood. moreover, the continuous gas flow enhances gas mixture in the lungs also improving gas exchange. altogether, fcv results in more efficient ventilation as compared to conventional ventilation techniques. evone® is the only commercially available ventilator applying fcv ventilation mode, thus directing the inspiration as well as the expiration [ figure 2 ]. evone's fcv® ventilation mode is based on a controlled inspiration and expiration flow from a set peep to a set peak pressure and vice versa. the inspiratory flow is continuously controlled by advanced mass flow regulators; the expiratory flow is controlled by regulated suctioning. evone is to be used in combination with tritube [ figure 3 ], an ultra-thin endotracheal tube (outer diameter 4.4 mm/ inner diameter 2.4 mm), enabling highly accurate intra-tracheal pressure measurements and securing the airway with an inflatable high volume -low pressure cuff because fcv ventilation requires a sealed airway. with an outer diameter (od) of only 4.4 mm, tritube® is an ultrathin ventilation tube, intended to obtain endotracheal access to the airway and to ventilate an adult patient [ figure 3 ]. tritube has three lumina: a ventilation lumen -with murphy eye and an inner diameter (id) smaller than 3 mm; a cuff lumen -to inflate and deflate the high volume, low pressure cuff; and an intra-tracheal pressure measurement lumen -for continuous intra-tracheal pressure measurements. tritube (including its cuff) is completely manufactured of polyurethane. additionally, tritube has a malleable stylet to facilitate intubation [8, 9] . this study aims to demonstrate the positive effects on oxygenation of flow-controlled ventilation compared to conventionally ventilated patients (pressure control ventilation) in patients suffering from ards associated with covid-19. primary outcome: we choose as the primary endpoint arterial oxygen partial pressure (pao2). • minute volume • arterial co2 (paco2) • tube obstruction by secretion hmc-irb,mrc-05-018,14apr20-13apr21 we will collect demographic data (age, sex, bmi), co-morbidities and clinical data (need for special intervention, e.g. "proning") drugs used and fluids administered. next to the vital parameters (blood pressure, heart frequency and body temperature) the oxygenation parameters (bga) will be collected 6-8 hourly according to clinical standard. kidney-function parameters (creatinine, urea), liver function tests and whole blood counts and immune-parameters like interleukin 6 (il-6) will be recorded. cardiac enzymes will be collected (troponin, bnp) will be evaluated and reported on clinical need. all of these parameters are reported routinely on daily base for clinical purpose. demographic parameters: • • i: e ratio • abg this is a prospective, randomized feasibility study in adult patients with proven covid-19 associated ards. we define ards according to "berlin" definition integrating the oxygenation index (p/f ratio), the level of peep and clinical findings [3, 4] . we will use an envelope method to randomize patients into the flow-control ventilation group (group a) while all other patients will receive standard treatment (pressure control ventilation-group b). due to the nature of the investigation (we use a special device and tube) blinding of the study groups will not be possible. the study will be performed in hmc facilities hosting covid-19 patients. after admission to the icu for covid-19 associated respiratory disease, the patients (or their relatives) will be approached, informed about the study and if agreed informed consent will be taken. upon intubation the severity of the disease will be assessed thrice daily. when the patient fulfils the criteria for moderate to severe ards (p/f ratio between 100mmhg and 200 mmhg with peep of minimal 5 cmh2o and below 100mmhg with a minimal peep 5 cmh2o, respectively) randomization will be performed. hereafter the group a patients will receive the ultra-thin tritube through the existing tube. this does not need exchange of the tube, so it does not generate additional risks for the staff in terms of aerosols. for the safety of the staff, only the investigators will be in the room and perform the change to the tritube. this will be done under full ppe. via the existing tube the ultra-thin tritube will be inserted. for this purpose, the existing tube will be clamped, and the ventilator will be set on hold. then the connector with the inlet for the tritube will be connected and the tritube will be inserted. hereafter, the clamp will be removed, and the ventilator will be re-started. then the tritube will be advanced, blocked and connected to the evone-ventilator. the ventilator settings will be started with the pre-existing-peep and the standard ventilator will be set on hold. the upper pressure will be determined to achieve a tidal volume of 6 ml/kg lean body mass, while the respiratory rate will be set to maintain an arterial bga?? above 7.2 ph. in this group the ventilator settings will be adjusted by the icu team (respiratory therapist) in agreement with lung-protective ventilation strategy [3a,4]. all other treatment will be unchanged and according to our local policies/guidelines. in all groups the first clinical data collection starts after 1 hour of initiation of the "new" ventilation strategy. the study ends at 48 hours after insertion of the tritube or if the patient deteriorates needing pronepositioning or ecmo therapy. all adult patients admitted to the hospital (hmgh, hgh) because of covid-19 infection who develop a moderate to severe ards are eligible. we want to ensure there is no risk for our patients. therefore, we propose a review of our first 4 patients regarding quality and safety by a dmsb. if the irb agrees we could provide names of intensive care doctors experienced in research. study duration and timelines expected duration of the study:6 months start time: asap (april 2020) data collection: 1 month data-analysis: 3 months preparing a publication: 2 months hmc-irb,mrc-05-018,14apr20-13apr21 demographic data, laboratory data, vital parameters and clinical data will be collected via the electronic patient chart (cerner). we will maintain privacy for the subject throughout data collection by carrying out data collection in private rooms. data confidentiality will be maintained by the use of study ids rather than any identifying data. all data will be entered into a secure database, which is password protected with restricted access, only assigned by the research team. each subject will be assigned an alphanumeric study id, to ensure data confidentiality. the link between the identifier and the study code will be deleted at the end of the study and the anonymized data set will be kept for at least 5 years after study completion per mrc policy. after explaining the project details, a written informed consent will be obtained from patient/ or family member if the patient is not able to give consent. the family member chosen for the consent will be the one who is patient's next of kin. subjects can withdraw from the study at any point and this will not be held against them. they will be informed during the consent process of this and will be asked to contact the research team so that the investigator can withdraw them from the study. if a subject should withdraw, the data and samples collected will be destroyed, unless they have already been analyzed or processed or coded. power-calculation: in order to keep the total number of patients small we will match the patients according to age, co-morbidities inhaled oxygen fraction and we regard this investigation as a feasibility study. therefore, the sample size calculation based on the assumption of an effect size (change in pao2) of 1.5 sds in the primary endpoint (pao2), an intended power of 80%, an alpha error of 5% and an equal sample ratio results in n=7 patients needed to treat. however, to compensate for dropouts we will include 10 patients in each group, which means in total 20 patients. data analysis: categorical data will be presented as number and percentage, while interval data will be presented by median and interquartile range (iqr). normally distributed data will be analyzed by using two-tailed unpaired students t-test. continuous variables with skewed distribution will be analyzed using mann-whitney u testing and dichotomous variables by means of fisher's exact test. a p-value <0.05 is considered significant. all data analyses will be done using spss version v26 (ibm corp, armonk ny, usa). graphs will be constructed using graphpad prism (graphpad prism version 5.0a for windows, graphpad software, san diego ca, usa). although we do not expect adverse events we will follow and report all adverse effects to ensure safety for the patients. • the study will only be conducted after review and approval from mrc and ethical committee of irb. • all participating patients/or patient's family member will be asked for informed consent after explanation of the project and giving written information. • there will be no change in treatment plan with the exception of the ventilation. • we will maintain privacy for the subject throughout data collection by carrying out data collection in private rooms or areas that are partitioned. • data confidentiality will be maintained by the use of an individual study id which is stored in a key file together with the identifier separately and safely. all collected data will be stored under the nominator of the study id. all information is stored in a secured computer file in a locked office in hgh. • all research is done under recognition of the helsinki declaration and under full adherence to the moph regulations in qatar. we rely on our own staff and devices hmc financial support for additional devices might be needed. we are planning to present this study in local or international conference and published it in indexed journal (not decided) after completion of study. 14. study population and study setting/ location error! bookmark not defined. data collection, data management & confidentiality not defined. hmc-irb case-fatality rate and characteristics of patients dying in relation to covid-19 in italy clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study acute respiratory distress syndrome: new definition, current and future therapeutic options guidelines on the management of acute respiratory distress syndrome flow-controlled ventilation during ear, nose and throat surgery: a prospective observational study flow-controlled ventilation attenuates lung injury in a porcine model of acute respiratory distress syndrome: a preclinical randomized controlled study flow-controlled ventilation -a novel approach to treating severe acute respiratory distress syndrome ventilation for low dissipated energy achieved using flow control during both inspiration and expiration improved lung recruitment and oxygenation during mandatory ventilation with a new expiratory ventilation assistance device key: cord-336058-xz26rbav authors: wintner, lisa m.; giesinger, johannes m.; sztankay, monika; bottomley, andrew; holzner, bernhard title: evaluating the use of the eortc patient-reported outcome measures for improving inter-rater reliability of ctcae ratings in a mixed population of cancer patients: study protocol for a randomized controlled trial date: 2020-10-13 journal: trials doi: 10.1186/s13063-020-04745-w sha: doc_id: 336058 cord_uid: xz26rbav background: in oncology, detection and tracking of adverse events are of top priority and rely mostly on the common terminology criteria for adverse events (ctcae). besides, clinical trials use as well patient-reported outcomes (pros) to assess those adverse events, which are only accessible through patient self-reporting, such as fatigue, pain, and sleep disorders. especially those issues that are not visible from the outside are often misinterpreted and underestimated by mere provider ratings. this trial aims at evaluating the impact of providing pro data to providers on the accuracy of adverse event assessment in terms of inter-rater reliability of ctcae ratings. methods: the trial uses a cross-sectional, unblinded, randomized controlled trial design with two trial arms and a single assessment time point. eligible patients (aged 18 and above, any cancer diagnosis, currently under treatment, inpatient or day clinic setting, present symptom burden, no psychiatric or mental problems, written informed consent) complete an electronic version of the eortc qlq-c30 and 16 additional questions taken from the eortc item library. pro data is immediately processed and made available to ctcae rating providers for conducting their ratings during the medical encounter. patients are randomly assigned 1:1 to the intervention group (providers see pro results on the same screen as the ctcae rating) and the control group (no access to pro data during the ctcae rating). a superiority analysis will compare the inter-rater reliability (using intra-class correlation (icc) coefficients) between the control and the intervention groups for each adverse event evaluated. discussion: the presented trial will demonstrate potential benefits of using pro measures to improve the reliability of ctcae ratings in cancer trials and the identification of adverse events. the new insights gained may lead to a new strategy for evaluating adverse events in clinical trials by combining patient and provider ratings. this might also have implications for daily clinical practice and cancer registries. trial registration: clinicaltrials.gov nct04066868. registered on august 26, 2019. competence center for clinical trials of the medical university of innsbruck 20190513-2007. registered on may 14, 2019. (version 6.0, march 18, 2019) in oncology, the common terminology criteria for adverse events (ctcae) (developed by the us-american national cancer institute (nci) of the national institute of health (nih) [1] ) are an established method to evaluate and document the toxicities in clinical studies. ctcae are a provider-based (clinicians or nurses) grading system, which facilitates the classification of adverse events (aes) regarding their severity from mild to life-threatening to event-related death. during the last decades, the growing awareness of the importance to complement the traditional provider-rated assessment of the patient's health status by patient-reported outcomes (pros) triggered the development of valid and reliable instruments [2] . as "a measurement of any aspect of a patient's health status that comes directly from the patient" [3] without being interpreted or altered by anyone else, pro represents the gold standard to capture the patient's perspective regarding his/her health status. pro covers a wide range of both complex concepts such the patient's functioning (physical, social, emotional, cognitive), depression, or anxiety as well as specific symptoms and overlaps strongly with ctcae, especially with regard to the latter. though the parallel collection of ctcae and pro ratings reflects a common practice in cancer clinical trials, their combination in order to maximize information yield is still uncharted territory. several studies found substantial discrepancies when it comes to comparisons of ae ratings from patients with those from providers. for non-observable symptoms such as fatigue or dyspnea, concordance of patient and clinician ratings was worse than for observable symptoms such as vomiting and diarrhea [4] and patients rated symptoms like fatigue, dyspnea, or skin toxicities more frequently and more severely than providers did [5] [6] [7] . clinician ratings also lack sensitivity [2] and underestimate the severity of aes [4] . a review of the literature on direct comparisons of pro and ctcae also reports that predominantly poor to moderate associations between clinical and patient-based aes can be observed [8] . thus, especially for those aes, which can only be assessed via patients' self-reports, the integration of pros to collect information on aes is a worthwhile strategy to improve this situation. besides the lacking concordance of patient-based and provider-based ae ratings, it is notable that even providers often achieve only moderate agreement. the ctcae system itself has not undergone a formal validation procedure [5] , and to the best of our knowledge, only two studies have investigated reliability of ctcae ratings and reported only moderate rater agreement [9, 10] . considering the abovementioned findings, integrating patient assessment with pro measures into a multimethod strategy for ae identification may result in a substantial improvement of clinical trial methodology. to date, pro and ctcae ratings have been used in parallel rather than as a combined source for drug safety information. integrating pro data providing standardized information on toxicities into the process of ctcae rating may increase inter-rater reliability as well as ae identification, in particular with regard to lowgrade toxicity that is not related to salient clinical events such as unplanned hospitalization. the trial aims at evaluating the impact of providing pro data to providers on the accuracy of ae information, assessed by using ctcae ratings. as there is no gold standard for ae ratings available, accuracy will be investigated in terms of inter-rater reliability. the primary trial endpoint is the inter-rater reliability of ctcae provider ratings for 17 aes in cancer patients with mixed diagnoses. a superiority analysis will compare the inter-rater reliability between the control and the intervention groups for each assessed ae. there are two secondary trial endpoints: (1) difference in the frequency of identified aes (any grade) between the intervention and control group and (2) the comparison of the differences in inter-rater reliability between the intervention and control group across the different types of aes. the selection of ctcae toxicities is based on the aes detected by the european organization for research and treatment of cancer quality of life core questionnaire (eortc qlq-c30), which cover symptoms normally associated with chemotherapeutic treatments. in addition, aes associated with immunotherapy have been added as this treatment option is becoming increasingly common in various diagnoses. the following 17 ctcae toxicities will be assessed in this trial: anxiety, depression, irritability, concentration impairment, memory impairment, fatigue, pain, dyspnea, nausea, vomiting, insomnia, anorexia, diarrhea, constipation, peripheral sensory neuropathy, rash, and pruritus. the trial objectives will be investigated using a crosssectional, unblinded, randomized controlled trial design with two trial arms and a single assessment time point. the medical university of innsbruck acts as the trial sponsor. the trial will be conducted at six different sites across europe and asia: county hospital of kufstein (kufstein, at), besançon university hospital (besançon, fr), martin-luther-university halle-wittenberg (halle, de), university of cagliari (cagliari, it), general king hussein cancer centre (amman, jor), and kansai medical university hospital (osaka, jp). the trial will recruit inpatients or those attending oncology day care. patient recruitment is planned for a duration of 27 months. to be eligible for inclusion in the trial, patients have to fulfill the following inclusion criteria: patients aged 18 or above any cancer diagnosis (no more than 20% per diagnostic group) current treatment with chemotherapy or immunotherapy inpatient or day clinic setting scoring 3 or above on an initial screening question ("on a scale from 0 to 10, to what degree did you experience physical or emotional symptoms/ problems during the last week?") no psychiatric or mental problems (i.e., no such diagnosis in the medical records) written informed consent participating providers are requested to be either a medical, surgical, or radiation oncologist by training or a specially trained nurse authorized to perform ctcae assessments in clinical trials, both with at least 1-year experience in oncology. the only criterion for trial dropout is the participant's wish to do so. this applies to both providers and patients. withdrawal is possible at any time and does not result in any negative consequences for the former participant. during their day clinic or inpatient stay, all patients provide pro data by autonomously completing questionnaires (eortc qlq-c30 and additional items from the eortc item library) on a tablet pc. subsequently, after having a medical encounter with the patient, two providers conduct consecutive, independent ctcae ratings (intervention group: including pro data, control group: no additional information). all data will be collected on the same day. figure 1 depicts the trial flow, and fig. 2 shows the standard protocol items recommendations for interventional trials (spirit) figure [11] . the software computer-based health evaluation system (ches [12] ) is used for electronic pro questionnaire completion, collection of ctcae ratings, and completion of electronic crfs. if it is necessary to assess pros with paper questionnaires, the questionnaires will be entered into the system right after completion into the trial database to allow in the intervention group electronic result presentation to the provider. each provider has an individual login, granting access to ctcae ratings and preventing double ratings by the same provider. login to the software is possible via any computer or mobile device with an internet connection. providers receive the instruction to open the ches software upfront the patient encounter and to complete the ctcae rating during the consultation. allocation of providers to patient ctcae ratings does not follow a predefined rule. providers on duty are requested to complete ctcae rating on the same day the patient has completed pro data. if during medical consultations the need for additional treatment or sideeffect management becomes apparent, the provider in charge will provide medical advice or referral to other specialists. in the control group, providers use the assessment software to access and complete the ctcae rating in an electronic format. in the intervention group, providers see the respective patient's pro data next to the corresponding ctcae domain, when accessing the rating. for an example of the ctcae rating with and without displayed pro data, see fig. 3 . in addition, providers can access the individual pro questions and answers. this is especially important for subscales of the eortc qlq-c30, which comprise different ctcae categories (e.g., the questions of the scale eortc emotional functioning include the single ctcae categories depression, anxiety, and irritability). thus, the intervention is the additional provision of pro data to providers who complete a ctcae rating for the respective patient. to allow for a naturalistic setting, providers do not receive any special training in ctcae ratings. the pro assessment software processes a 1:1 randomization to the control or intervention group for each study center. in order to ensure balance between the two groups, minimization is applied when the patient's basic data is added to the database. for this, a weighted cutoff is determined taking the sizes of control and intervention groups into account. next, a random number between 0.0 and 1.0 is generated. if the random number is smaller than the cutoff, the patient is added to the group with less patients. in order to determine weight, the randomization procedure has been simulated and weight = 0.05 has been determined to produce the desired trade-off between balancing the two groups and preventing predictable group assignments. for each patient, a detailed randomization log is produced, which allows tracing all steps of the randomization procedure. providers cannot be blinded in this trial. at the time of pro assessment, patients do not know whether they are assigned to the study or the control group. collection of ae ratings is done for those ctcae toxicities that are also covered in the eortc qlq-c30 and aes, which are common in patients receiving immunotherapy (peripheral sensory neuropathy, rash, and pruritus). the case report form for patients contains an eligibility checklist (cancer diagnosis, age at diagnosis above 18 or above, current chemotherapy or immunotherapy, ability to understand the questionnaire cognitively and linguistically, written informed consent provided, no psychiatric or mental problems) and a data sheet for clinical and sociodemographic data (sex, age, country of origin, marital status, living situation, education level, employment status, date of diagnosis, diagnosis, metastasis, disease stage, recurrence, current treatment and treatment intention, concurrent medication, comorbidities, performance status). for patients who discontinue or refuse to participate in the study, the reasons for their decision, sex, age, and diagnosis are documented. for providers, age, sex, specialty, years of professional experience, previous participation in clinical trials, and research experience (self-reported years of experience) are collected on a separate sheet. patients complete a total of 46 questions covering 17 adverse events listed in the ctcae. the eortc qlq-c30 by the european organization for research and treatment of cancer (eortc) quality of life group [13] was originally developed for use in clinical trials, covers physical and psychosocial aspects, and is one of the most widely used instruments in europe. it consists of 30 items assessing 5 functioning scales (physical, social, role, emotional, and cognitive functioning), 3 symptom scales (fatigue, pain, and nausea/vomiting), 6 singleitem symptoms (appetite loss, dyspnea, diarrhea, constipation, sleeping difficulties, financial difficulties), and a global health and quality of life scale. in addition, 16 items have been taken from the eortc item library to supplement those ctcae domains which are covered by one question in the eortc qlq-c30 and to include aes common in chemotherapy and immunotherapy (peripheral sensory neuropathy, rash, and pruritus). the nci has published standardized definitions for aes, known as the common terminology criteria for adverse events (ctcae), to describe the severity of organ toxicity for patients receiving cancer therapy. the most recent ctcae version 5.0 was published in november 2017 and became effective in april 2018 [1] . in this trial, providers rate the following 17 ctcae toxicities: anxiety, depression, irritability, concentration impairment, memory impairment, fatigue, pain, dyspnea, nausea, vomiting, insomnia, anorexia, diarrhea, constipation, peripheral sensory neuropathy, rash, and pruritus. for the ctcae ratings, the electronic form includes an info box that shows the exact definitions for each grade as given in the ctcae version 5.0. depending on the respective domain, rating from grade i to iii or iv is possible. an additional "below grade i" category allows the provider to report that a certain problem is not present (or not qualifying for grade i or above). only complete data sets will be used for final analysis. for analysis of the primary trial endpoint, we will compare inter-rater reliability of ctcae ratings separately for each domain using intra-class correlation (icc) coefficients. we would like to note that difference in icc is an unusual endpoint, and to the best of our knowledge, no recommendations are available from the literature what constitutes a minimal important difference in icc. according to cicchetti [14] , iccs can be classified as follows: < 0.40 poor, 0.40-0.59 fair, 0.60-0.74 good, and > 0.75 excellent. this is consistent with the classification by fleiss et al. [15] . for the analysis of the secondary trial endpoints, iccs will also be compared across aes to evaluate differences in the reliability of the ctcae ratings across different types of aes (e.g., aes differing in observability). in addition to intra-class correlations, we will also compare percentage of absolute agreement of ratings and percentage for deviations by one and two grades. the frequency of identified aes (any grade) will be compared between the intervention and control group using fisher exact tests. a sample size of 1024 patients (512 per group) allows to detect differences in icc with an effect size of q = 0.174 (alpha = 0.05, beta = 0.20, two-sided). this effect size corresponds to differences in reliability of, e.g., 0.20 vs 0.36, 0.40 vs 0.54, or 0.60 vs 0.70. power analysis for icc has been approximated by pearson correlation coefficients as suggested by streiner et al. [16] . the planned sample size is sufficient to detect a difference corresponding to about half a category width in this classification. data is stored securely on an eortc server. patient data is entered and stored pseudonymized, i.e., that patients receive an id from the respective study center, which makes it impossible to determine the identity of the individual patient within the system. an id list is kept at each participating center, with which depseudonymization can be carried out; this list remains at the center and is stored there in accordance with data protection regulations. each collaborating center will perform data quality management by conducting plausibility checks (e.g., checking minimum and maximum values) and identifying missing values. final data analysis will be conducted at the institution of the principal investigator. a data safety monitoring board is not considered necessary as the study does not include procedures, medications, or interventions that expose patients to a risk of potential harm. conducting safety audits would possibly cause more inconvenience to patients than it would protect them from possible risks, which are practically not to be expected when filling out a questionnaire and conducting a medical interview. in accordance with the rules of the project and module development committee of the eortc quality of life group, an interim scientific report on the progress of the study will be prepared before each of the six-monthly meetings of the eortc quality of life group in order to monitor recruitment rates and identify areas for improvement. providing evidence for improved ctcae ratings in cancer trials may have a substantial impact on how pros are used in future trials and further strengthen the perceived relevance of the patients' perspective (operationalized by using pro measures) for outcome and safety assessment in cancer research. this may result in a new ae assessment strategy making combined pro and provider ratings the new standard method. naturally, enhanced ae assessment is beneficial not only in the context of clinical trials, but also with regard to daily oncological practice, cancer registries, and pharmacovigilance. at the time of submission of the protocol (version 6.0, march 18, 2019) for publication, two centers were collecting data, recruitment started in early february 2020, three were in the final phase of study set-up, and one had to postpone patient recruitment until autumn 2020 due to the covid-19 pandemic. according to the recruitment phase of about 27 months, recruitment will continue until about early 2022 or until the required number of patients is enrolled in the study. the study results will be published in an international journal, presented as lectures and/or posters at national and international conferences, and communicated online (e.g., as a supplement to the study registrations and using other relevant media). the scientific writing will be done by the principal investigator and the project management without external professional authors. the consort guideline will be referred to for the reporting of results. co-authors must comply with the vancouver rules of authorship with regard to scientific articles at the time of submission. there are no publication restrictions. authors' contributions bh is the principal investigator; he designed the study and led the development of the proposal and the protocol. lmw, jmg, ms, and ab contributed to the study design and development of the proposal. jmg is the lead study methodologist. lmw and ms drafted the manuscript. bh and jmg supervised manuscript writing. the authors read and approved the final manuscript. the trial is funded by a grant awarded from the eortc quality of life group (grant number 005-2018). the trial design has undergone a peer review process of the funder (including internal and external reviewers). the funder has no role in the data collection, data management, analysis, and interpretation. the data gathered by conducting this trial may be made available by the eortc (https://www.eortc.org/request-for-data/) upon reasoned request. the ethics committee of the medical university of innsbruck approved the trial (1020/2019, april 24, 2019). all participating centers will obtain ethical approval of their respective ethics committee in accordance with local regulations. written, informed consent to participate will be obtained from all participants before study inclusion. it is the responsibility of the local study coordinator of each participating center to inform patients accordingly about the purpose of the study, possible risks, and benefits, to obtain the necessary data and to ensure data protection. the patient information sheet contains detailed information that all recorded data are subject to the general data protection regulation (eu) 2016/679 (gdpr) and that patients can exert their rights regarding their personal data at any time (including data on contact persons and information sources). the patient information sheet and the consent form can be obtained from the corresponding author upon request. common terminology criteria for adverse events (ctcae) version 5 quality of life: the assessment, analysis and interpretation of patient-reported outcomes guidance for industry: patientreported outcome measures: use in medical product development to support labeling claims: draft guidance patient versus clinician symptom reporting using the national cancer institute common terminology criteria for adverse events: results of a questionnaire-based study patient-reported outcomes and the evolution of adverse event reporting in oncology exploring differences in adverse symptom event grading thresholds between clinicians and patients in the clinical trial setting comparison of provider-assessed and patient-reported outcome measures of acute skin toxicity during a phase iii trial of mometasone cream versus placebo during breast radiotherapy: the north central cancer treatment group (n06c4) the level of association between functional performance status measures and patient-reported outcomes in cancer patients: a systematic review reliability of adverse symptom event reporting by clinicians reliability at the national cancer institute-common toxicity criteria version 2.0. gan to kagaku ryoho spirit 2013 statement: defining standard protocol items for clinical trials the computer-based health evaluation software (ches): a software for electronic patient-reported outcome monitoring the european organization for research and treatment of cancer qlq-c30: a quality-of-life instrument for use in international clinical trials in oncology guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology statistical methods for rates and proportions health measurement scales: a practical guide to their development and use springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations none. not applicable. key: cord-334667-0cah15lg authors: arabi, yaseen m.; asiri, ayed y.; assiri, abdullah m.; aziz jokhdar, hani a.; alothman, adel; balkhy, hanan h.; aljohani, sameera; al harbi, shmeylan; kojan, suleiman; al jeraisy, majed; deeb, ahmad m.; memish, ziad a.; ghazal, sameeh; al faraj, sarah; al-hameed, fahad; alsaedi, asim; mandourah, yasser; al mekhlafi, ghaleb a.; sherbeeni, nisreen murad; elzein, fatehi elnour; almotairi, abdullah; al bshabshe, ali; kharaba, ayman; jose, jesna; al harthy, abdulrahman; al sulaiman, mohammed; mady, ahmed; fowler, robert a.; hayden, frederick g.; al-dawood, abdulaziz; abdelzaher, mohamed; bajhmom, wail; hussein, mohamed a. title: treatment of middle east respiratory syndrome with a combination of lopinavir/ritonavir and interferon-β1b (miracle trial): statistical analysis plan for a recursive two-stage group sequential randomized controlled trial date: 2020-01-03 journal: trials doi: 10.1186/s13063-019-3846-x sha: doc_id: 334667 cord_uid: 0cah15lg abstract: the miracle trial (mers-cov infection treated with a combination of lopinavir/ritonavir and interferon-β1b) investigates the efficacy of a combination therapy of lopinavir/ritonavir and recombinant interferon-β1b provided with standard supportive care, compared to placebo provided with standard supportive care, in hospitalized patients with laboratory-confirmed mers. the miracle trial is designed as a recursive, two-stage, group sequential, multicenter, placebo-controlled, double-blind randomized controlled trial. the aim of this article is to describe the statistical analysis plan for the miracle trial. the primary outcome is 90-day mortality. the primary analysis will follow the intention-to-treat principle. the miracle trial is the first randomized controlled trial for mers treatment. trial registration: clinicaltrials.gov, nct02845843. registered on 27 july 2016. middle east respiratory syndrome (mers) is a viral respiratory disease caused by the middle east respiratory syndrome coronavirus (mers-cov). mers cases continue to occur and are often associated with respiratory and multiorgan failure [1] . there is no antiviral treatment with proven efficacy at present [1, 2] . the miracle trial (mers-cov infection treated with a combination of lopinavir/ritonavir and interferon-β1b) is the first randomized controlled trial for mers treatment. the study protocol has been previously published [3] . there are several challenges in a trial for treatment of a disease like mers: (1) there is not enough information on the effect size of the lopinavir/ritonavir and interferon-β1b provided with standard supportive care compared to placebo provided with standard supportive care to conduct adequate planning for the study sample size; (2) mers is a sporadic, unpredictable, and rare disease, which makes it difficult to plan a separate pilot study to collect the necessary information needed for the planning of the main trial. to overcome these challenges, we designed the miracle trial as a recursive two-stage adaptive trial, which is a relatively new method for group sequential trials [4] [5] [6] [7] . the approach is based on the conditional error principle, which allows for flexible and continuous adjustment of the trial parameters using data observed during prior stages without inflation of the type i error [8] . another advantage of this method is the flexibility in setting the timing and the number of needed interim analyses. such flexibility is necessary in a situation where recruitment rate is unpredictable and a sudden flux in recruitment of patients could happen at any time. finally, the design takes advantage of the accumulated information throughout the trial from every single recruited patient as opposed to a traditional two-study approach (pilot followed by the main trial). in this article, we describe the miracle trial statistical analysis plan (sap) in advance of trial completion. we identify the procedures to be followed for the primary and secondary analyses for the trial. the sap was written by the study steering committee members led by the principal investigator, who remains blinded to both group allocation and to study results until after completing patient recruitment, patient follow-up, and completion and locking of the database. the final study report will follow the guidelines of the consolidated standards of reporting trials (consort) for reporting randomized controlled trials [9, 10] . the trial is being conducted according to the standard requirements of good clinical practice e6 [11] . the sap was developed in accordance with the international council for harmonisation guidelines (e9 statistical principles for clinical trials and e3 clinical study reports guidelines) [12, 13] and with the guidelines for the content of statistical analysis plans in clinical trials [14] . the miracle trial is a recursive, two-stage, group sequential, multicenter, randomized, placebo-controlled, double-blind trial. the trial includes hospitalized patients who are 18 years old or older with laboratoryconfirmed mers in addition to evidence of acute organ dysfunction that is judged related to mers. inclusion and exclusion criteria have been detailed in a previously published protocol manuscript [3] . patients are randomized to receive lopinavir/ritonavir and recombinant interferon-β1b or placebo. randomization is stratified according to center and according to whether the patients require mechanical ventilation (invasive or noninvasive) at the time of enrollment, as mechanical ventilation is a major, but pragmatic, surrogate for severity of illness. the study interventions continue for 14 days or until hospital discharge. patients are followed up daily until day 28 or hospital discharge and then at day 90. a consort flow diagram of the trial progress will be constructed (fig. 1 ). the number of randomized patients to each group will be reported as well as the number of randomized patients who received the interventions. we will also report the number of screened patients (defined as all hospitalized patients with mers) who met the eligibility criteria but were not enrolled and the reasons for non-enrollment. the intention-to-treat population consists of all enrolled patients whether or not they received the allocated intervention, and will be used for the primary analysis. a per-protocol analysis will be conducted for patients who received the allocated interventions (defined by any dose of the study intervention). baseline characteristics will be presented for the two study groups (additional file 1: table s1 ) including age, sex, and body mass index, the presence of co-infections, nosocomial versus community-acquired mers infection, acute physiology and chronic health evaluation (apa-che) ii scores, sequential organ failure assessment scores, and the karnofsky performance status scale score [3] . we will report comorbidities and the interventions received before randomization for the patients in each group. we will report baseline laboratory values (international normalization ratio, platelet count, hemoglobin, white blood cell count, lymphocyte count, liver enzymes, glucose, serum amylase, blood urea nitrogen, creatinine, creatine kinase, lactate) and respiratory and vital parameters in addition to the location of the patient at time of randomization. for each group we will report the time of hospital admission to randomization and the time of randomization to the first dose received of the study drugs. we will report the received study intervention and its duration for each group, in addition to the missing or incomplete doses and protocol violations (additional file 1: table s2 and table s8 ). we will compare any use of vasopressors, renal replacement therapy, neuromuscular blockade, mechanical ventilation, extracorporeal membrane oxygenation (ecmo), nitric oxide, prone ventilation, and tracheostomy. we will also compare the use of intravenous immunoglobulin, antiviral therapy, antibiotics, corticosteroids, and statins (additional file 1: table s2 ). the primary outcome is 90-day mortality (additional file 1: table s3 ). the primary outcome is defined as all-cause mortality after enrollment in the trial within 90 days, as either an inpatient or outpatient. secondary outcomes and subgroups are defined as presented in table 1 and additional file 1: table s4 , and s5). in addition, we will compare the physiological parameters among patients treated in the treatment group and the control group. all analyses will be performed using sas 9.4 with specially written code for the analysis of the primary supplemental oxygen-free days number of days within the first 28 days after enrollment when patients do not receive of supplemental oxygen. patients who die within 28 days will be assigned the value "0" renal replacement therapy-free days number of days within the first 28 days after enrollment when patients do not receive of renal replacement therapy. patients who die within 28 days will be assigned the value "0" vasopressor-free days number of days within the first 28 days after enrollment when patients do not receive of vasopressors. patients who die within 28 days will be assigned the value "0" invasive or non-invasive mechanical ventilation-free days number of days within the first 28 days after enrollment when patients do not receive of mechanical ventilation. patients who die within 28 days will be assigned the value "0" organ support-free days number of days within the first 28 days after enrollment when patients do not receive of invasive mechanical ventilation, renal replacement therapy and vasopressor. patients who die within 28 days will be assigned the value "0" extracorporeal circulation support-free days number of days within the first 28 days in which patients are not receiving extracorporeal circulation support. patients who die within 28 days will be assigned the value "0" icu-free days number of days in which patients are not being cared for in the icu during the first 28 days after enrollment. patients who die within 28 days will be assigned the value "0" post-randomization hospital length of stay number of days between randomization and discharge from the hospital. because of the competing risk effect of death on length of stay, length of stay will be also reported for survivors alone the number and percentage of reported serious adverse events any time during the study period. these saes include: acute pancreatitis, severe elevation of alanine aminotransferase (alt) to more than five-fold the upper normal limit, anaphylaxis, bleeding diathesis and others the number and percentage of adverse events graded using the common terminology criteria for adverse events, at any time within 28 days after enrollment. the adverse drug reactions include: allergic reactions, gastrointestinal, general nervous system and others. see also table s6 functional outcomes karnofsky score karnofsky performance status scale for functional impairment, which is a scale from 100 (indicating "normal," no complaints; no evidence of disease) to 0 (indicating death) at day 90 outcome that accounts for the recursive design, as described in chang [4] . a detailed interim analysis plan is reported in the mir-acle protocol [3] . the trial is designed as a recursive, two-stage, group sequential randomized trial. the first interim analysis will be conducted when 34 subjects (17 per group) have completed 90 days of follow-up. this is about 17.5% of the total sample size needed for the classical design (a classic two-group design requires a total of 194 subjects (97 subjects per group) to have an 80% power at a significance level of 5% using a one-sided z test for difference in proportion to detect 20% absolute risk reduction in 90 days mortality among subjects receiving treatment (20%) compared to a control group (40%)). a data and safety monitoring board (dsmb) will be convened to review the unblinded data (efficacy and safety) and advise on continuation or termination of the trial. the determination of the stopping boundaries in the first two-stage design was calculated using the conditional power method based on the summing stagewise p values. at the first interim analysis, the dsmb will determine whether the trial should be terminated for futility or not using the following boundaries and their corresponding decisions ( table 2) . we will summarize and report the demographics and baseline clinical characteristics using descriptive statistics. as appropriate, the chi-square test or fisher's exact test will be used to compare the categorical variables, which will be reported as numbers and percentages. student's t test or the mann-whitney u test will be used as appropriate to compare the continuous variables, which will be reported as means and standard deviations or as medians and interquartile ranges. all adverse events will be grouped using common terminology criteria for adverse events (ctcae) version 4 of the national institutes of health (nih) (additional file 1: table s6 ). adverse events will be grouped into aggregate groups and reported for the entire study period (additional file 1: table s7 ). all results will be summarized in terms of frequency and percentage and will be compared across study arms using fisher's exact test. all results will be declared statistically significant with a p value < 0.05. let k be the number of stages of the current clinical trial needed to complete the trial and i ∈ {1, 2} be the index for the two-stage design in the k th stage. let r 1ki and r 2ki be the proportions of 90 days mortality in the standard of care and treatment group respectively. then the z test statistic for the difference in proportion can be calculated as follows: where n ki is the sample size per group for the i th twostage design of the k th stage. in the interim analysis (i.e., at each i = 1 of the k th two-stage), the primary outcome will be evaluated, and the trial sample size will be reestimated for the subsequent stage based on the observed effect size using the following formula assuming a conditional power of 80% (pc = 0.8) to decide if the trial should continue: here α k, 2 is the precalculated rejection boundary for efficacy at the second stage of the two-stage design at the k th stage, and p k, 1 is the raw table probability corresponding to the z ki statistic. at the first interim analysis, should the data suggest that another stage of the twostage steps is required, we will recalculate the conditional error and new boundaries will be calculated for k = 2. let β k + 1, 1 , α k + 1, 1 be the rejection boundaries for futility and efficacy for the first (i = 1) of the twostage step of the k th + 1 stage. then the conditional error is: efficacy stopping boundary (α 2 ) 0.2250 stop trial for efficacy at the second stage or recalculate based on conditional power at first interim analysis α1 is the maximum probability threshold under which the trial will be terminated early for efficacy. β1 is the maximum probability threshold above which the trial will be terminated for futility. α2 is the maximum probability threshold (the sum of the stage-wise p-values), above which the study will be declared as met its endpoint where a(p 0, 1 ) is the type i error, which is set to 0.05. the new α k + 1, 2 boundary for the k th + 1 stage for pre chosen β k + 1, 1 , α k + 1, 1 will be calculated as follows: at the end of the trial, the treatment will be declared efficacious if the calculated stage-wise ordered p value p k, 2 is less than α k, 2 . the adjusted p value will be obtained using backward recursion as follows: where k 0 is the total number of two-stage stages, and t is the sum of stage-wise raw p values. finally, the adjusted overall 95% one-sided confidence interval will be calculated by: where δ i, 1 and δ k 0 ;2 are the stage-wise and the last stage of the kth two-stage design confidence interval bound. the last stage confidence bound δ k 0 ;2 can be found by solving the following equation numerically for δ k 0 ;2 : where n k0, 1 and n k0, 2 are the sample sizes for the first and second stage of the last k th two-stage design, and p k0, 1 , p k0, 2 are the stage-wise adjusted p values. in order to stay consistent with the method that was used in calculating the boundaries for the trial, we will not account for stratification in the primary outcome analysis. in general, this approach is acceptable and it preserves both type i and type ii errors as long as the weighted average of the effect size stays close to the hypothesized effect size [15] . furthermore, as long as the sample size re-estimation at the interim analysis was based on the weighted average of the effect size, the overall power of the trial will be preserved. with the exception of the analysis of the primary outcome, all other analyses will be tested using regular statistical methods and will be two-sided. a secondary adjusted analysis will be conducted using multiple logistic regression analysis, in which death within 90 days will be modeled as the dependent variable, and a set of baseline variables that are strongly believed to affect the outcome of mers will be included as independent variables. those variables will include at minimum the following: age, community-acquired versus hospital-acquired infection, mechanical ventilation, center, and sequential organ failure assessment score. ninety-day median survival time will be summarized and reported using kaplan-meier curves and will be compared between the study groups using the log-rank test (additional file 1: figure s1 ). analysis of secondary outcomes will be compared in the intention-to-treat cohort only. subgroup analyses will be conducted if patient numbers permit (e.g., no fewer than five patients in subgroups of interest) in a priori defined subgroups (additional file 1: table s5 ). multivariable logistic regression will be used to report the results of tests of interactions for these subgroups. all missing data will be reviewed and characterized in terms of their pattern (e.g., missing completely at random, missing at random, etc.). for missing completely at random, all analyses will be based on a list-wise deletion approach where only observations with complete values will be considered for analysis. for variables with values missing at random, multiple imputation techniques will be utilized to impute the missing values, as suggested by rubin [16] . to adjust for multiple testing, we will use the false discovery rate (fdr) as described by benjamini and hochberg [17] . in this procedure all hypothesis tests will be sorted in ascending order based on their calculated p value. all hypothesis tests below an index k will be rejected, where k is calculated as follows: where i = m, … ,1, m is the total number of tested hypotheses, and q = 0.05. additional details about the sap are available in additional file 2. the miracle trial investigates the efficacy of a combination therapy of lopinavir/ritonavir and recombinant interferon-β1b provided with standard supportive care, compared to placebo provided with standard supportive care, in hospitalized patients with laboratory-confirmed mers. the first patient was enrolled in november 2016. at present, 14 sites are actively screening for eligible patients. the recruitment rate in the miracle trial has been slow mainly related to the decline in the number of mers cases in saudi arabia. due to the uncertainty of the efficacy level of the treatment and the recruitment rate, the trial is designed to be a recursive, two-stage, group sequential randomized trial [4] . several methods could be utilized to build an adaptive trial. however, most of these methods would require one to specify a priori the time and type of adjustments that need to take place in the trial. for a disease such as mers there are many factors that could limit the ability to specify a priori those elements; thus, the recursive two-stage design is a natural choice. this type of design provides enough flexibility to introduce different adjustments while learning from the observed data without inflating the type i error. reporting of the sap to the miracle trial in advance of trial completion will enhance evaluation of the clinical data and support confidence in the final results and the conclusion. prior specification of the statistical methods and outcomes analysis will facilitate unbiased analyses of these important clinical data. recruitment started in november 2016 and is currently ongoing. supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-019-3846-x. additional file 1: table s1 . baseline characteristics of intention-to-treat (itt) population. table s2 . summary of interventions and cointerventions. table s3 . primary outcome: 90-day mortality. table s4 . secondary outcomes. table s5 . subgroup analyses. table s6 . classification of adverse events in the miracle trial (mers-cov infection treated with a combination of lopinavir/ritonavir and interferon-β1b) using the nih common terminology criteria for adverse events (ctcae), version 4.0. table s7 . summary of adverse events by severity. table s8 . summary of protocol violations. middle east respiratory syndrome saudi critical care trials group. ribavirin and interferon therapy for critically ill patients with the middle east respiratory syndrome: a multicenter observational study treatment of middle east respiratory syndrome with a combination of lopinavir-ritonavir and interferon-beta1b (miracle trial): study protocol for a randomized controlled trial adaptive design theory and implementation using sas and r benefit-risk evaluation of multi-stage adaptive designs draft guidance for industry on enrichment strategies for clinical trials to support approval of human drugs and biological products; availability flexible interim analyses in clinical trials using multistage adaptive test designs modification of the sample-size and the schedule of interim analyses in survival trials based on data inspections explanation and elaboration: updated guidelines for reporting parallel group randomised trials statement: updated guidelines for reporting parallel group randomised trials harmonisation of technical requirements for registration of pharmaceuticals for human use: good clinical practice (gcp) guideline the international council for harmonisation of technical requirements for pharmaceuticals for human use (ich): statistical principles for clinical trials international conference on harmonisation of technical requirements for registration of pharmaceuticals for human use: e3 -structure and content of clinical study reports guidelines for the content of statistical analysis plans in clinical trials robustness of an odds-ratio test in a stratified group sequential trial with a binary outcome measure multiple imputation after 18+ years controlling the false discovery rate: a practical and powerful approach to multiple testing publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to acknowledge the following data safety monitoring board (dsmb) chair the miracle trial is funded by king abdullah international medical research center, riyadh, kingdom of saudi arabia. the study sponsor does not have any role in the study design, collection, management, analysis or interpretation of the data, or in writing the report. the datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. the miracle study is approved by the scientific committee and the institutional review board at the national guard health affairs, riyadh, saudi arabia (rc15/142) and all participating sites and registered at the saudi food and drug authority (sfda), riyadh, saudi arabia. patients who meet the eligibility criteria or substitute decision-makers (for patients lacking decisionmaking capacity) of eligible patients will be approached to obtain informed consent for enrollment. not applicable. the authors declare that they have no competing interests. ya and fgh are unpaid consultants on antivirals active for mers for gilead sciences, sab biotherapeutics, and regeneron. key: cord-336368-sudi4mdx authors: thiruvenkatarajan, venkatesan; dharmalingam, ashok; arenas, gilberto; wahba, medhat; steiner, reinhard; kadam, vasanth rao; tran, andre; currie, john; van wijk, roelof; quail, anthony; ludbrook, guy title: high-flow nasal cannula versus standard oxygen therapy assisting sedation during endoscopic retrograde cholangiopancreatography in high risk cases (other): study protocol of a randomised multicentric trial date: 2020-05-29 journal: trials doi: 10.1186/s13063-020-04378-z sha: doc_id: 336368 cord_uid: sudi4mdx background: endoscopic retrograde cholangiopancreatography (ercp) is an increasingly common intervention in the treatment of pancreaticobiliary disorders. patients are often elderly with complex co-morbidities. while monitored anaesthesia care with sedation is commonly used for most cases, few would require general anaesthesia with an endotracheal tube. both low-flow and high-flow nasal cannulas (hfnc) are established ways of delivering supplemental oxygen, but it is unclear whether one technique is better than the other. hfnc seems a promising tool for advanced procedures but evidence to support its application in high-risk ercp cases is limited. the rate of oxygen desaturation during endoscopy has been reported to be as high as 11%–50% and the method of oxygen delivery for ercp merits further study. methods/design: this is a prospective, randomised, multicentre trial comparing the efficacy of oxygen supplementation through hfnc versus low-flow nasal cannula during ercp, in a cohort of patients at risk of adverse respiratory events. a total of 132 patients will be recruited across three sites and randomly assigned to either the low-flow or the hfnc group. the primary outcome is the proportion of patients experiencing hypoxia, defined by any event of spo2 < 90%. the secondary outcomes include parameters centred on oxygenation, requirement of airway manoeuvres, successful completion of procedure, perioperative complications, patient satisfaction and cost analysis of the consumables. an intention-to-treat principle will be applied while analysing. discussion: the demand for ercps is likely to increase in the future with the aging population. our study results may lead to improved outcomes and reduce airway-related complications in patients undergoing ercps. the results will be presented at national and international meetings and published in peer-reviewed journals. trial registration: www.anzctr.org.au, ctrn12619000397112. registered on 12 march 2019. (continued from previous page) discussion: the demand for ercps is likely to increase in the future with the aging population. our study results may lead to improved outcomes and reduce airway-related complications in patients undergoing ercps. the results will be presented at national and international meetings and published in peer-reviewed journals. trial registration: www.anzctr.org.au, ctrn12619000397112. registered on 12 march 2019. keywords: endoscopic retrograde cholangiopancreatography, oxygen therapy, low-flow oxygen cannula, high-flow oxygen cannula, hypoxia background endoscopic retrograde cholangiopancreatography (ercp) is a common intervention in the treatment of biliary and pancreatic diseases, and the demand for ercp is increasing. there are several difficulties for the anaesthetist to deal with. it is generally performed in a prone or lateral position under moderate to deep sedation or general anaesthesia [1] [2] [3] . in most hospitals, ercp is usually performed outside the operating room. the patients who require this procedure are typically elderly with significant comorbidities. general anaesthesia with an endotracheal tube may be a 'safe option' in the prone position in terms of having a secured airway and a lower ercp failure rate [3] ; there may be a reduction in complication rates, but intubation has drawbacks. in addition to the well-known problems associated with insertion of the tube, managing a paralysed intubated patient prone creates its own challenges. note that there is frequently a prolongation of anaesthetic time concurrent with the use of muscle relaxants. deep sedation using propofol is perhaps the most commonly employed technique for ercps. ercp generally requires a deeper level of sedation compared to simple gastroscopy and there is an increased risk of both partial and complete airway obstruction. the goals of deep sedation are: preserving adequate spontaneous ventilation; maintaining cardio-respiratory stability; early recovery; and minimising any hypoxaemia at all times. hypoxemia and aspiration have occurred when these procedures have been performed under deep sedation, especially in high-risk cases [4] . reasons for desaturation during ercp under deep sedation have been attributed to reduced cardiopulmonary reserve, advanced age, respiratory depression, duration of the procedure, and prone positioning. the incidence of hypoxemia during any endoscopic procedure is in the range of 11%-50% [5] [6] [7] and it is possibly as high as 60% with ercp [8] (definitions of hypoxia vary between the studies). prolonged hypoxia is a major risk factor for periprocedural cardiac arrhythmias and myocardial ischaemia [9] [10] [11] . any methods of avoiding such occurrences is worthy of investigation. regardless of the level of sedation, supplemental oxygen is regularly administered to all patients to prevent hypoxia. conventionally, it is delivered via nasal prongs and/or an extension tubing attached to the mouth guard (the application of the endoscope in the oral cavity precludes the use of normal face masks). the recommended flow rate through the low flow nasal cannula is 2-4 l/ min, while the inspired fio 2 (fractional inspired oxygen concentration) is dependent on the ventilatory minute volume, in the range of 0.27-0.50 [12, 13] . patients with high american society of anesthesiologists (asa) status (iii) [5, 14] , high body mass index (bmi) [5, 15] and those with obstructive sleep apnoea (osa) [16] are especially at an increased risk of hypoxia during advanced endoscopic procedures such as ercp; these patients will obtain most benefit from any improvement in oxygenation techniques. it has been the case that superior oxygen delivery options preserving spontaneous respiration without interfering with the pharyngeal cavity have been limited for these procedures. high-flow nasal cannula (hfnc) is a new approach for improving oxygenation and ventilation that has gained popularity in procedural sedation. it has been demonstrated to provide better oxygenation compared to the venturi face mask and low-flow nasal cannula during intravenous sedation for both bronchoscopy and dental procedures [17, 18] . hfnc can provide a maximum flow up to 70 l/min and delivers a flow-dependent positive airway pressure which increases end-expiratory lung volume and thereby improves oxygenation [19] . it has numerous physiological advantages that are not possible through standard (ventilation dependent) low-flow delivery systems. these advantages include the ability to create peep (up to 5-7.5 cm h 2 0), reduce the work of breathing, provide constant fio 2 up to 100%, provide good humidification, and aid washout of the pharyngeal dead space [19, 20] . in one centre, introducing the option to use hfnc affected anaesthetic practice and decreased the usage of general anaesthesia with an endotracheal tube (for a mixed group of ercp and endobronchial ultrasound procedures) [21] . this observational study also showed hfnc also decreased the anaesthesia only time. high-flow nasal oxygen has been described in the critical care setting for respiratory impairment for nearly a decade [20] . it has been successfully employed in various perioperative settings such as preoxygenation and airway management, including awake intubation [22, 23] . in our own institution, we have used hfnc for endoscopy and ercp procedures in high-risk cases and have found it convenient to use and frequently beneficial. being administered nasally, there is nil interference with the endoscopic insertion and manipulation in the oropharynx. the aim of the other (oxygen therapy in high risk ercp) trial is to assess the efficacy and safety of oxygen supplementation achieved through hfnc compared with low-flow nasal cannula during ercp in a cohort of patients at risk of adverse respiratory events. we hypothesise that the application of high-flow nasal oxygen will reduce the incidence of major respiratory adverse events and any resulting cardiovascular problems. measurements will be made of respiratory and haemodynamic parameters, recovery profile and patients' satisfaction. we will conduct this prospective multicentre randomised trial as per the recommendations for interventional trials (spirit, fig. 1 and additional file 1) [24] . the final reporting of this trial will be in accordance with the consolidated standards of reporting trials (consort) statement. the other trial will be conducted across three australian hospitals: the queen elizabeth hospital and royal adelaide hospital, south australia, and john hunter hospital, new south wales. a total of 132 patients will be recruited. ercp procedures are unique in terms of their presentation. a good proportion of them are undertaken as semi-urgent cases (unlike other pure electively planned cases) as inpatients and they may not get the opportunity to present to a pre-admission clinic. we are planning to recruit these patients at least 2 h before the procedure or whenever they are being assessed for anaesthesia. during this time, the patient information sheet will be provided. the recruitment and consenting are done by one of the investigators or by the anaesthetists assessing these patients. the pre-screening process would be based on the inclusion criteria mentioned below. participants will be randomly assigned to either the lowflow nasal oxygen or the hfnc group at a ratio of 1:1 (fig. 2) . the randomisation scheme will be generated by the clinical trials division of the pharmacy department at the queen elizabeth hospital. to ensure equal distribution of the intervention arm, stratification is done in specific blocks to predetermined numbers known only to the clinical trials division. this will be revealed only at the end of the trial. the random numbers and the group assignment will be supplied in sealed envelopes and handled only by the principal investigator. a set of 25 envelopes will be dispatched and used at each site, and an additional set of envelopes will be dispatched in blocks of 20 once the first 25 are used. the envelopes will be opened just before commencing ercp and groups are allocated to the treatment intervention. participants and the investigators are not blinded to the allocation. the patient information sheet contains descriptions of the trial. diagrams of hfnc as well as low-flow nasal cannula are depicted in the sheet. further, when we commence hfnc, we are obliged to explain to the patient that they will feel a high flow of oxygen coming through their nostrils. these are the reasons why we could not blind the participants to the intervention. data will be collected only by the investigators. the data analysts will be blinded to the intervention. adults (aged > 18 years) fulfilling any of these criteria: asa 3 or 4; obesity (bmi > 30 kg/m 2 ); obstructive sleep apnoea diagnosed either by polysomnography; being treated with cpap for osa; suspected osa based on stop bang score >/3 (stop bang is an acronym for snoring, tiredness, observed choking/gasping, blood pressure elevation, bmi increase, age, neck size, male gender). participants fulfilling any of the below criteria will be excluded: (1) deemed 'difficult airway' and/or difficult intubation based on clinical judgement and known previous difficult airway; (2) severe cardio-respiratory compromise or any other indications that necessitate the procedure to be done under general anaesthesia with endotracheal tube; (3) patients judged to be at significant risk of pulmonary aspiration. risk assessment will be based on patient history (focusing particularly on risk factors for aspiration) and physical examination. possible risk factors for aspiration include: increased gastric content; delayed gastric emptying; including lap band in situ; lack of fasting (< 6 h for solids and 2 h for clear fluid); increased regurgitation risk: uncontrolled or symptomatic gastro-oesophageal reflux, oesophageal strictures, zenker diverticulum and achalasia; laryngeal incompetence due to cerebral infarct, head injuries, neuromuscular disorders (parkinson's disease, gullian barre), muscular dystrophies (cerebral palsy, cranial neuropathies); and (4) emergency surgery and any other criteria warranting general anaesthesia with an endotracheal tube. patients will be randomly allocated (computer-generated randomisation) to either the low-flow nasal oxygen group (group l; n = 66) or the high-flow nasal oxygen group (group h; n = 66). in group l, the procedure will be performed under deep sedation and analgesia, with supplemental oxygen 4 l/min via regular nasal cannula and a further supplemental oxygen source with a flow rate of 4 l/min administered through an extension tubing attached to the mouth guard. in group h, the procedure will be performed under deep sedation and analgesia similar to group l, with oxygen delivered through a hfnc. this will be accomplished using the optiflow thrive (transnasal humidified rapid insufflation ventilatory exchange) device (opti-flow, auckland, new zealand). flow rate through the cannula will be commenced at 30 l/min and fractional inspired oxygen concentration will be set at 100%. the flow will be gradually increased after the administration of sedative agents and will be maintained at 50 l/min during the procedure. the flow rate may be either increased up to 70 l/min if necessary or decreased to 30 l/min if the patient does not tolerate the higher flow rate (50 l/min is very well tolerated in even very lightly sedated patients). standard monitoring will be applied, including continuous electrocardiogram, blood pressure automatically measured every 3 min, transcutaneous capnography and pulse oximetry. the procedures will be done in either the lateral or prone positions. a standard sedation technique will be applied for both groups. sedation is to be provided by titrated doses of fentanyl 0.5-1.0 mcg/kg, as required, and a propofol target controlled infusion (using the marsh model) commencing at an initial plasma target of 1.5-2.0 mcg/ml and titrated up or down during the procedure, between target values of 1-4 mcg/ml based on satisfactory depth of anaesthesia and frequency of ventilation (8-14 breaths per min). administration of further fentanyl top up doses (25 mcg) will be at the anaesthetist's discretion. in all cases, airway obstruction needs to be avoided. if it is deemed necessary that during the intervention phase, if the participants' clinical condition warrants an advanced airway such as tracheal intubation, it will be undertaken and they will be retained in an intention-to treat analysis. the occurrence of hypoxia, defined by any event of spo2 (oxygen saturation measured by pulse oximetry) < 90% of any duration, will be compared between the two groups. secondary outcomes are as follows: number of events of hypoxia, defined as desaturation < 90%. the mean number of events during the procedure will be compared between the two groups; lowest recorded spo 2 during the procedure; transcutaneous co 2 . maximum value recorded and average value during the case. the mean values during the procedure will be compared between the two groups; lowest recorded spo 2 % during the procedure. the mean values during the procedure will be compared between the two groups; requirement of minor airway manoeuvres: jaw lift/ jaw thrust, nasopharyngeal airway insertion. proportion of patients requiring these manoeuvres will be compared between the two groups; requirement of major airway manoeuvres: bag mask ventilation, endotracheal intubation. proportion of patients requiring these manoeuvres will be compared between the two groups; arrhythmia (any change in cardiac rhythm observed on the electrocardiogram). proportion of patients manifesting arrhythmia during the procedure will be compared between the two groups; total fentanyl dose. the mean values (the doses in micrograms) during the procedure will be compared between the two groups; requirement of antispasmodic agent. proportion of patients requiring this medication will be compared between the two groups; total duration of procedure (starting from sedation until leaving the suite). the mean duration in minutes will be compared between the two groups; duration under sedation/anaesthesia: measured from the time of induction till eye opening. the mean duration in minutes will be compared between the two groups; successful completion of the procedure: yes/no. proportion of patients fulfilling this criterion will be compared between the two groups; early complicationselicited as patients leave recovery; dry mouth/nose/throat: binary outcome (constant pain or discomfort in the mouth/nose/ throat). proportion of patients experiencing this adverse event will be compared between two groups: • sensation of abdominal bloating: y/n. proportion of patients experiencing this adverse event will be compared between the two groups; patients' satisfaction score on leaving recovery: 5 points numerical rating scale: • very satisfied (5), somewhat satisfied (4), neither satisfied nor dissatisfied (3), somewhat dissatisfied (2), very dissatisfied (1). proportion of patients at a particular threshold will be compared between the two groups; cost analysis of the consumables: low flow versus high flow. this will be analysed for only the consumables required during the procedure for an average case and compared across the two groups. the information will be obtained from our clinical pharmacy and anaesthetic nursing department. a 21.4% incidence of hypoxia (spo 2 < 90% for 15 s) was noted in an australian study during ercp with propofol sedation in older patients (20) . assuming a 16% reduction in hypoxic events by employing the hfnc technique (given the rate of hypoxia as 21.4% in the sedation group and an estimated 5.4% in the hfnc group), with a power of 80% and an alpha error of 0.05, a total of 132 patients would be required (66 in each arm). mean and standard deviation values will be estimated for continuous outcomes while frequency and percentage will be computed for binary outcomes. 95% confidence intervals around the point estimate will be calculated where appropriate for the primary and secondary outcomes. descriptive statistics will be used to present the results. p < 0.05 will be considered significant. analyses will be intention-to-treat from randomisation. all randomised cases will be included in the analyses, regardless of missing data. as the data capture is only limited to a few hours after the intervention and the investigators are directly involved in the conduct of the study, we anticipate very few missing data. a subgroup analyses will be attempted (if feasible) for the high bmi and osa groups combined. our study is the first multicentre randomised controlled trial comparing low-flow versus high-flow nasal oxygen therapy for improving oxygenation in high-risk patients for ercp. there are standardised and objective endpoints. in addition, patient-reported outcome measures are explored. the application of transcutaneous co 2 measurements helps to overcome the limitation of expired co 2 monitoring during ercp. the nature of the study precludes blinding of the participants and the anaesthetists, which may contribute to bias and influence the results. the investigators and anaesthetic nursing staff will undergo special training on using and troubleshooting the transcutaneous co 2 equipment. only data on respiratory, haemodynamic and perioperative outcome endpoints will be collected during the procedure and it is not time bound. only one set of data will be collected in the post-anaesthesia care unit when they leave the area. the data will be de-identified when entered into an excel spreadsheet for analysis. no blood or tissue samples will be collected. the original data collection will be kept for cross-checking. the data forms will be securely placed in our department's locked filing cabinets. any serious adverse events across any sites will be notified within 24 h to the principal investigator. patient recruitment and data quality will be regularly checked by the investigators across the trial centres. the study involves comparing established standard practices and hence deemed as low risk to be specifically monitored by a data monitoring committee. the electronic data will be stored in the department's computers with password protection. after the analysis, only the principal investigator will have access to the data. a strict privacy policy will be maintained by all investigators to protect confidentiality throughout the trial process. this study will be performed in accordance with the standard protocol items: recommendations for interventional trials [spirit] recommendations. . the results of the study will be disseminated through peer-reviewed publications and national/ international conference presentations. protocol amendments will be immediately notified to all centres. the increasing demand for ercps on a cohort of patients with multiple co-morbidities, along with time constraints in optimising these patients when it is attempted on a semi-urgent basis, has generated an enormous interest in the quest for exploring better airway management strategies. hfnc is one such device that has been attempted across a variety of settings requiring sedation. besides the primary outcome assessing the occurrence of hypoxia, secondary outcomes of airway intervention and patientreported scales are also measured. the risks are very negligible from these two nasal cannulas. they have been in use for many years as standard methods of delivering oxygen. the patients will be asked for symptoms of dryness of mouth or throat or nose after the procedure as part of outcome measures. if dryness develops, it normally settles within a few hours. these outcome measures are aimed at detecting some of the known side effects of oxygen delivery. the hfnc can cause abdominal distension, particularly in children after prolonged use. at the end of this procedure, endoscopists routinely evacuate any insufflated gas from the stomach and this will mitigate any such risk in this group. there are no other specific safety issues concerning hfnc for participants and administering staff. the results may lead to improved outcomes and reduce airway-related complications in patients undergoing ercps. in our opinion, the results will also deliver meaningful information on the role of hfnc-assisted sedation in any setting. the recruitment commenced in february 2019 and the trial is expected to be completed by september 2020. currently, the trial is on hold in view of the aerosolisation concerns with hfnc therapy during the covid-19 outbreak. supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04378-z. additional file 1. spirit checklist. endoscopic retrograde cholangiopancreatography in elderly patients anaesthetic considerations during endoscopic retrograde cholangiopancreatography evaluation of endoscopic retrograde cholangiopancreatography under conscious sedation and general anesthesia sedation and safety of propofol for therapeutic endoscopic retrograde cholangiopancreatography incidence of sedationrelated complications with propofol use during advanced endoscopic procedures sedation in gastrointestinal endoscopy: a prospective study comparing nonanesthesiologist-administered propofol and monitored anesthesia care risk factors for hypoxemia during ambulatory gastrointestinal endoscopy in asa i-ii patients use of the gastrolaryngeal tube in endoscopic retrograde cholangiopancreatography cases under sedation/analgesia prevention of hypoxaemia during upper-gastrointestinal endoscopy by means of oxygen via nasal cannulae hypoxaemia and myocardial ischaemia during colonoscopy silent myocardial ischaemia during endoscopic retrograde cholangiopancreatography acute oxygen therapy low-flow oxygen: how much is your patient really getting? a prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ercp with anesthesiologist-administered sedation obesity as a risk factor for sedation-related complications during propofol-mediated sedation for advanced endoscopic procedures a screening instrument for sleep apnea predicts airway maneuvers in patients undergoing advanced endoscopic procedures high-flow nasal interface improves oxygenation in patients undergoing bronchoscopy a nasal high-flow system prevents hypoxia in dental patients under intravenous sedation clinical evidence on high flow oxygen therapy and active humidification in adults high-flow nasal cannula oxygen therapy in adults high-flow nasal oxygen availability for sedation decreases the use of general anesthesia during endoscopic retrograde cholangiopancreatography and endoscopic ultrasound optimizing oxygenation and intubation conditions during awake fibre-optic intubation using a high-flow nasal oxygen-delivery system transnasal humidified rapid-insufflation ventilatory exchange (thrive): a physiological method of increasing apnoea time in patients with difficult airways spirit 2013 explanation and elaboration: guidance for protocols of clinical trials publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations not applicable. 2 discipline acute care medicine, the university of adelaide, adelaide, south australia, australia. 3 department of anaesthesia, john hunter hospital, new lambton heights, new south wales, australia. 4 the royal adelaide hospital, adelaide, south australia, australia. 5 flinders medical centre, bedford park, south australia, australia. 6 department of anaesthesia, the queen elizabeth hospital, woodville, south australia, australia. 7 human physiology anaesthesia and intensive care, school of medicine and public health, the university of newcastle, callaghan, new south wales, australia. authors' contributions vt: principal investigator, conceived and designed the study, primary author of the manuscript; ad: principal investigator at john hunter hospital; ga: principal investigator at royal adelaide hospital; mw, rs, vrk: coinvestigators at the queen elizabeth hospital; jc: co-author and contributed to the design and writing the manuscript; at: co-author, will be involved in data collection and analysis; rvw: co-author, contributed to critical approval of the manuscript, approved the final version and supervision of the study; aq: co-author, contributed to critical approval of the manuscript, approved the final version and supervision at john hunter hospital; gl: co-author, trial set-up and design, critical appraisal of the protocol and supervision of the trial. authorship for trial publications will be determined based on the individual author's contribution to the study. the use of professional writers is not planned. the author(s) read and approved the final manuscript. the other trial is investigator-initiated and received a grant from fisher & paykel healthcare limited, 15 maurice paykel place, east tamaki, auckland 2013, new zealand for publication of the protocol and to cover the cost incurred with the consumables of transcutaneous co 2 monitoring. the study protocol has undergone peer review by the funding body. the funding body (fisher & paykel) did not contribute to trial design and will not be involved in data collection, analysis, interpretation and publishing the results. as no datasets were generated or analysed for this trial at this stage, data sharing is not applicable. the principal investigator vt will have access to the final trial dataset. trial and data details can be obtained from the principal investigator upon reasonable request. key: cord-292544-m7jyydf1 authors: grau-pujol, berta; camprubí, daniel; marti-soler, helena; fernández-pardos, marc; guinovart, caterina; muñoz, jose title: pre-exposure prophylaxis with hydroxychloroquine for high-risk healthcare workers during the covid-19 pandemic: a structured summary of a study protocol for a multicentre, double-blind randomized controlled trial date: 2020-07-29 journal: trials doi: 10.1186/s13063-020-04621-7 sha: doc_id: 292544 cord_uid: m7jyydf1 objectives: the aim of this study is to assess the efficacy of the use of pre-exposure prophylaxis (prep) with hydroxychloroquine against placebo in healthcare workers with high risk of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection in reducing their risk of coronavirus disease 2019 (covid-19) disease during an epidemic period. as secondary objectives, we would like to: i) assess the efficacy of the use of prep with hydroxychloroquine against placebo in healthcare workers with high risk of sars-cov-2 infection in reducing their risk of exposure to sars-cov-2 (defined by seroconversion) during an epidemic period, ii) evaluate the safety of prep with hydroxychloroquine in adults, iii) describe the incidence of sars-cov-2 infection among healthcare workers at high risk of sars-cov-2 infection, iv) identify clinical, analytical and microbiological predictors of covid-19 among healthcare workers at high risk of sars-cov-2 infection, v) set up a repository of serum samples obtained from healthcare workers at high risk of sars-cov-2 infection for future research on blood markers to predict sars-cov-2 infection. trial design: multicentre double-blind parallel design (ratio 1:1) randomized controlled clinical trial. participants: approximately 440 healthcare workers of four spanish hospitals (hospital clínic of barcelona, hospital de la santa creu i sant pau of barcelona, hospital plató of barcelona, hospital general de granollers, barcelona) will be recruited. participants are considered to be at high-risk of sars-cov-2 infection due to their frequent contact with suspected and confirmed cases of covid-19. for eligibility, healthcare workers with 18 years old or older working at least 3 days a week in a hospital with both negative sars-cov-2 polymerase chain reaction (pcr) assays and serological covid-19 rapid diagnostic tests (rdt) are invited to participate. participants with any of the following conditions are excluded: pregnancy, breastfeeding, ongoing antiviral, antiretroviral or corticosteroids treatment, chloroquine or hydroxychloroquine uptake the last month or any contraindication to hydroxychloroquine treatment. intervention and comparator: intervention group (prep): participants will receive the standard of care and will take 400mg of hydroxychloroquine (2 tablets of 200 mg per dolquine® tablet) daily the first four consecutive days, followed by 400 mg weekly for a period of 6 months. control group: participants will receive placebo tablets with identical physical appearance to hydroxychloroquine 200 mg (dolquine®) tablets following the same treatment schedule of the intervention group. both groups will be encouraged to use the personal protection equipment (ppe) for covid-19 prevention according to current hospital guidelines. main outcomes: the primary endpoint will be the number of confirmed cases of a covid-19 (defined by a positive pcr for sars-cov-2 or symptoms compatible with covid-19 with seroconversion) in the prep group compared to the placebo group at any time during the 6 months of the follow-up in healthcare workers with negative sars-cov-2 pcr and serology at day 0. as secondary endpoints, we will obtain: i) the sars-cov-2 seroconversion in the prep group compared to placebo during the 6 months of follow-up in healthcare workers with negative serology at day 0; ii) the occurrence of any adverse event related with hydroxychloroquine treatment; iii) the incidence of sars-cov-2 infection and covid-19 among healthcare workers in the non-prep group, among the total of healthcare workers included in the non-prep group during the study period; iv) the risk ratio for the different clinical, analytical and microbiological conditions to develop covid-19; v) a repository of serum samples obtained from healthcare workers confirmed covid-19 cases for future research on blood markers to predict sars-cov-2 infection. randomisation: participants meeting all eligibility requirements will be allocated to one of the two study arms (prep with hydroxychloroquine or non-prep control group) in a 1:1 ratio using simple randomisation with computer generated random numbers. blinding (masking): participants, doctors and nurses caring for participants, and investigators assessing the outcomes will be blinded to group assignment. numbers to be randomised (sample size): each intervention group will have 220 participants, giving a total of 440 participants. trial status: the current protocol version is 1.5, 2(nd) of june 2020. two hundred and seventy-fiveparticipants were recruited and completed first month follow-up until date. the estimated sample size could not be reached yet due to the declining national epidemic curve. thus, 275 is the total number of participants included until date. the study has been suspended (26(th) of june) until new epidemic curve occurs. trial registration: this trial was registered on april 2(nd) 2020 at clinicaltrials.gov with the number nct04331834. full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. primary objective: 1) to compare the efficacy of the use of prep with hydroxychloroquine against placebo in healthcare workers with high risk of sars-cov-2 infection in reducing their risk of covid-19 disease during an epidemic period. secondary objectives: 1) to assess the efficacy of the use of prep with hydroxychloroquine against placebo in healthcare workers with high risk of sars-cov-2 infection in reducing their risk of exposure to sars-cov-2 (defined by seroconversion) during an epidemic period. 2) to evaluate the safety of prep with hydroxychloroquine in adults. primary endpoint: 1) confirmed cases of a covid-19 (defined by a positive pcr for sars-cov-2 or symptoms compatible with covid-19 with seroconversion) in the prep group compared to the placebo group at any time during the 6 months of the follow-up in healthcare workers with negative pcr for sars-cov-2 at day 0. secondary endpoints: 1) sars-cov-2 seroconversion in the prep group compared to placebo in during 6 months of follow-up in healthcare workers with negative serology at day 0. 2) the occurrence of any adverse event related with hydroxychloroquine treatment. we will compare the incidence of clinical and/or laboratory adverse events in the hydroxychloroquine prep group and the non-prep group. 3) incidence of sars-cov-2 infection and covid-19 among healthcare workers will be estimated by the number of healthcare workers diagnosed with covid-19 in the non-prep group, among the total of healthcare workers included in the non-prep group during the study period. 4) risk ratio for the different clinical, analytical and microbiological conditions to develop covid-19. 5) a repository (biobank) of serum samples obtained from healthcare workers confirmed covid-19 cases for future research on blood markers to predict sars-cov-2 infection. this study will be hospital-based and will be conducted at hospital clinic of barcelona, hospital de sant pau, hospital plató and hospital de granollers spain. all healthcare workers from hospital clinic, hospital de sant pau, hospital plató and hospital de granollers will be invited to participate. specifically, all healthcare workers with a negative pcr at the last hospital clinic routine sars-cov-2 screening will be also invited to participate. study personnel will inform them about the option to enrol in this study. on the day of the screening visit, the following procedures will be performed: -nasopharyngeal swab to conduct pcr to detect sars-cov-2. -detailed evaluation of previous medical history, allergies, current treatment, symptoms and physical examination (appendix 2). -12 ml of venous blood will be taken for the following determinations: -blood test (wbc, lymphocyte populations, haemoglobin, platelets, liver and kidney function, bilirubin, ldh, pcr) -rapid diagnostic serology test (rdt) for sars-cov-2 (igm and igg) -hiv serology -pregnancy test (women of reproductive age 18 -55 years old) -10 ml of venous blood to store two serum samples: -2ml to perform a serology test to detect sars-cov-2 immunoglobulins m and g (igm and igg) -2ml for biobank storage (for further research on diagnostics/biomarkers). 0 -1 ml of whole blood will be collected for hydroxychloroquine pk analysis. -one strip ecg (v2) to evaluate cardiac rhythm -informed consent (appendix 1) will be obtained from all healthcare workers willing to participate who fulfil the inclusion and exclusion criteria in case rdt serological test is negative at screening visit but the serum sampled stored to detect sars-cov-2 immunoglobulins m and g (igm and igg) is positive, the participant will be excluded from the analysis. participants fulfilling inclusion criteria and none of the exclusion criteria will be scheduled for recruitment visit. participants who fail to meet the inclusion and exclusion criteria will not, under any circumstances, be enrolled or receive study treatment. if any participant is enrolled by error, they will be withdrawn from the study, the pi notified and records kept. any participant incorrectly enrolled who started the intervention, will be followed up for ae. participants meeting all eligibility requirements will be allocated to one of the two study arms (prep with hydroxychloroquine or non-prep control group) in a 1:1 ratio. a real-time computer-generated randomization procedure will be used. at recruitment visit, a numbered case record form (crf, appendix 2) will be filled out for all potential participants. the first 2 tablets will be taken directly observed at the baseline visit. the rest of the tablets of the first month will be provided to the participant during that visit. the study will be double blinded. study participant flowchart regardless of their group of allocation, all participants will undergo the same procedures and will be followed-up monthly during 6 months. we will conduct active and passive surveillance to all of them. active surveillance to each participant will be conducted monthly, when a standardized crf will be filled out by the study team medical doctor conducting the visit. follow-up visits will include: any of the trial sites 1. detailed evaluation of symptoms and physical examination (to either detect past and current symptoms and signs related with covid-19 or past and current adverse events of hydroxychloroquine treatment since the previous visit) 2. known close contacts with suspected and/or confirmed covid-19 cases 3. assessment of compliance with prep and other preventive measures, including the number of weeks during which they have been managing covid-19 patients. 4. 12 ml of venous blood will be taken at month 1, 3 and 6 visits for the following determinations: wbc, lymphocyte populations, haemoglobin, platelets, liver and kidney function, bilirubin, ldh, pcr 5. 10 ml of venous blood to store two serum samples: ○ 2ml to perform a serology test to detect sars-cov-2 immunoglobulins m and g (igm and igg) ○ 2ml for biobank storage (for further research on diagnostics/biomarkers). 6. one strip ecg (v2) to evaluate cardiac rhythm in addition, on day 0, 3, 10, 31 (scheduled visit (m1)) and 61 (scheduled visit (m2)), 1 ml of whole blood will be collected to evaluate hydroxychloroquine concentrations. at every visit, the study medical doctor will also check for symptoms or possible adverse events. passive surveillance for each participant will be also conducted. a medical doctor will be available by phone 24 hours a day during the study period. all participants will be allowed to call this number in case of presenting any adverse event or symptom. in that case, a standardized crf will be filled out to collect the information. a chest x-ray and a nasopharyngeal swab will be performed to all those participants presenting with fever or respiratory symptoms. recruitment visit (day 0) publication and dissemination 5.8. biobank de-identified samples will be indefinitely stored at the hospital clinic de barcelona biobank for future use in other scientific projects related to sars-cov-2 infection. samples will be stored at the "colección de patología importada", registered at the hospital clínic-idibaps biobank and in the national biobank registry with code number c.0002610. those coded data and samples could be sent abroad to other research institutions for usage in research projects if necessary. in this case it will be assured that identical standards to the ones applicable for this research project are fulfilled. patients will sign a separated informed consent if they agree to the storage of their samples in the biobank (appendix 1) and the shipment of the samples to other institutions. with an expected incidence of 10% of covid-19 in healthcare workers in the control group and 2% in the hydroxychloroquine group, a hazard ratio of 0.2, for a significance level of 5%, statistical power of 90% and assuming a rate to lost-to-follow-up of 10%, a total of 440 subjects is required, 220 per group. (9) an intention-to-treat analysis will be conducted, with all patients fulfilling inclusion criteria and without exclusion criteria that have had at least one follow-up visit will be included in the analysis. participants will be censored when they are lost to follow-up (i.e. follow-up visits are not conducted), when they stop the intervention treatment or when they fulfill the primary endpoint. all clinical, epidemiological, microbiological and radiological data will be entered in the case report form (crf) (appendix 2) and introduced in a centralized database protected with username and password (using openclinica online database). for the statistical analysis software stata 15 or r will be used. descriptive analysis will be done for all healthcare workers with at least one follow-up visit. categorical variables will be expressed as absolute frequency and percentage. continuous variables will be expressed as mean and standard deviation (sd) or median and interquartile range (iqr). one sample kolmogorov-smirnov tests will be performed to assess whether variables were distributed normally. the following information will be recorded directly on the crf and will be considered source data: demography, household co-habitants, risk factors and concomitant medication. • bivariate analysis: normally distributed numeric parameters will be compared between groups using the t-test or anova. mann-whitney u-test or kruskal-wallis tests will be used for non-normal variables. categorical variables will be compared between groups using the pearson's chi-squared test or fisher's exact test if the expected frequency is < 5. • multivariate analysis: o cox regression models for investigating the association between time to sars-cov-2 infection (defined as symptoms compatible with covid-19 and/or a positive pcr for sars-cov-2) ) in the prep group compared to placebo group at any time during the 6 months of the follow-up, adjusted for age, sex, concomitant medication, concomitant diseases, laboratory parameters, number of weeks during which the participant was taking care of covid19 patients. o cox regression models for investigating the association between time to sars-cov-2 seroconversion (defined as igm or igg positive) in the prep group, compared to placebo in during 6 months of follow-up, adjusted for age, sex, concomitant medication, concomitant diseases, laboratory parameters, number of weeks during which the participant was taking care of covid19 patients. o linear regression models for investigating the association between quantitative pcr and treatment group, adjusted for age, sex, concomitant medication, concomitant diseases, laboratory parameters, number of weeks during which the participant was taking care of covid19 patients. hierarchical testing will be considered for secondary analysis. once the primary objective will be established, secondary analyses will be performed. interim analyses will be performed monthly and overall type i error will be controlled (see section 8). the study will be performed according to the declaration of helsinki (version of fortaleza, brazil, october 2013), current ich-gcp guidelines and all applicable national and local regulatory requirements (spanish royal decree 1090/2015). this study will be conducted under the auspices of a properly constituted ethics committee as defined by ich-gcp e6 (r2) guidelines and applicable regulations. this committee will review and approve the final study protocol and subsequent amendments, the final version of the informed consent form and any amendment and any other written information/material to be provided to the participants. prior to initiation of clinical activity, investigators will provide isglobal with a copy of the relevant ethics committee approval. if applicable, the investigators will be responsible for obtaining annual re-approval from the ethics committee. informed consent will be signed by all participants before their inclusion in the study. the study consent form will reflect the risks and benefits of participating in the study, and the specific sampling procedures to be done to each participant. sufficient time will be given to the participant's guardians to decide whether or not to participate in the study. candidates will be given the opportunity to enquire about the details of the study and any question regarding the study will be answered. participation in this study will be voluntary, and under no circumstances the clinical management of the participants will be affected by the decision to participate or not in the study. the participant will be free to withdraw at any time of the study. according to the ley orgánica 3/2018, del 5 de diciembre de protección de datos personales y garantía de los derechos digitales; and the reglamento ue 2016/679 del parlamento europeo y del consejo del 27 de abril de 2016, all information resulting from participating in the study will be confidentially treated. all data and samples collected will be allocated a study code so that they are unidentifiable. no use of any link to the participant's identity will be done. key identifying information will be kept in locked cabinets away from the coded samples and data and may only be accessed by the study investigators. management of patients diagnosed with covid-19 will be done following current national and hospital protocols. declaration of new confirmed covid-19 cases to agència de salut pública de barcelona, will be done as per normal practice. hospital clinic director will be also informed of any new case of covid-19, following current hospital protocols. samples obtained under the umbrella of the specific consent form will only be utilized for the purposes of this protocol, and under no circumstances will be used for other purposes as those specified both in the protocol and the consent form. the pis will ensure that the written information and the consent form are revised when an amendment to the study protocol is made and approved. a medical doctor will be available by phone 24 hours during the study period. all participants will be allowed to call this number in case of presenting any adverse event or worsening of symptoms. • from monday to friday, 8:30-17:00h: 610584612 • from monday to friday (17:00-8:30h) and weekends: 659106155 the principles of ich gcp require that specific procedures are set to notify and report adverse events in clinical trials. this is a responsibility of the sponsor and the study physician at each site. 8.1. adverse events and serious adverse events: adverse event means any untoward medical occurrence associated with the use of an intervention in humans, whether or not considered intervention-related. thus, any undesirable medical occurrence in a participant including those events which do not necessarily have a causal relationship to the study drug regimen. prior to the administration of study drug, only adverse events that meet the definition of serious (see below) and adverse events that the study physician considers to be related to study design and/or procedures should be recorded. any untoward medical occurrence that at any dose: • results in death • is a life-threatening adverse event • requires inpatient hospitalization or prolongation of existing hospitalization • results in a persistent or significant disability/incapacity or substantial disruption of the ability to conduct normal life functions • or a congenital anomaly/birth defect. important medical events that may not result in death, be life-threatening, or require hospitalization may be considered serious when, based upon appropriate medical judgment, they may jeopardize the participant and may require medical or surgical intervention to prevent one of the outcomes listed in this definition. adverse events will be assessed by direct observations of the study physician or reported by the participant. from the moment a study participant receives the study medication, the study physician will monitor each subject for the development of any clinical evidence of an ae. the nature of the adverse event, its date and time of onset, duration and severity, therapy employed (if any) and the investigator's opinion of causality to study drug with an alternate aetiology, if appropriate, will be documented. for adverse events to be considered as intermittent or continuous, the events should be of similar nature and severity. the investigator will follow all adverse events to satisfactory clinical resolution or the establishment of a stable chronic stage upon study completion. the investigator will rate the severity of the adverse event according to the following definition: mild: the adverse event is transient and easily tolerated by the subject. moderate: the adverse event causes the subject discomfort and interrupts the subject's normal activities. severe: the adverse event causes considerable interference with the subject's normal activities, and may be incapacitating or life-threatening. the study physician at each site will use the above definitions to assess the relationship of the adverse event to the study drug. the study physician at each site is obligated to assess the relationship between investigational product and the occurrence of each ae/sae. the study physician will use clinical judgment to determine the relationship. alternative causes, such as natural history of the underlying diseases, concomitant therapy, other risk factors, and the temporal relationship of the event to the investigational product will be considered. the degree of certainty about causality will be graded using the categories below. probably: an adverse event has a strong temporal relationship to study drug or recurs on re-challenge, and aetiology is unlikely or significantly less likely. possibly: an adverse event has a strong temporal relationship to the study drug, and an alternative aetiology is equally or less likely compared to the potential relationship to study drug. the alternate aetiology should be provided by the investigator. unlikely: an adverse event has little or no temporal relationship to the study drug and/or a more likely alternative aetiology exists. the alternate aetiology should be provided by the investigator. an adverse event is due to underlying or concurrent illness or effect of another drug and is not related to the study drug. the alternate aetiology should be provided by the investigator. the study physician will be responsible for determining whether an ae is expected or unexpected. an ae will be considered unexpected if the nature, severity, or frequency of the event is not consistent with the risk information previously described for the study intervention. the occurrence of an ae or sae may come to the attention of study personnel during study visits and interviews of a study participant presenting for medical care, or upon review by the study monitor. all aes including local and systemic reactions not meeting the criteria for saes will be captured in the crf. information to be collected includes event description, time of onset, the study physician's assessment of severity, relationship to study drug, and time of resolution/stabilization of the event. all aes that occur during the study duration must be documented appropriately regardless of the relationship. all aes will be monitored to adequate resolution. any medical condition that is present at the time that the participant is screened will be considered as baseline and not reported as an ae. however, if the study participant's condition deteriorates at any time during the study, it will be recorded as an ae. changes in the severity of an ae will be documented to allow an assessment of the duration of the event at each level of severity to be performed. aes characterized as intermittent require documentation of onset and duration of each episode. the study physician at each site will record all events with start dates occurring any time after informed consent is obtained until the last day of study. at each study visit, the study physician will inquire about the occurrence of ae/saes since the last visit. events will be followed for outcome information until resolution or stabilization. all saes will be reported to the sponsor by the study site physician or an assigned representative within 24 hours of the staff becoming aware of it, using a sae form, which should be completed, scanned and sent via email to the sponsor. the sae form should include nature of event, date of onset, severity, corrective therapies given, outcome and causality (i.e. probably, possibly, unlikely, unrelated). the study physician should assign the causality of the event. sae reporting will comply with local regulations for sae reporting to the sites research ethics committee and/or regulatory authorities. all unexpected saes must be reported to the ethics committee and the spanish regulatory agency (aemps) according to spanish legislation. in addition to the expedite sae reporting in 24h, monthly aggregate reports will be written by the study physician at each site. interim analyses of the efficacy and safety of hydroxychloroquine will be performed monthly and overall type i error will be controlled. after treatment initiation, hydroxychloroquine will be discontinued in participants presenting severe adverse events related to hydroxychloroquine intake or a confirmed sars-cov-2 infection by pcr assay in a nasopharyngeal swab or sputum sample. all serious adverse events will be notified to the sponsor. the study physician and investigator will evaluate the relationship with the study treatment. serious and unexpected adverse events that the cause is suspected to be related to hydroxychloroquine will be reported to the sponsor, to the ethical committee, to the pharmacy department of the hospital clinic of barcelona and to the agencia española del medicamento y producto sanitario (aemps). circumstances that may warrant termination or suspension of the study include: · determination of unexpected, significant, or unacceptable risk to participants · insufficient compliance to protocol requirements · data that are not sufficiently complete and/or evaluable · determination that the primary endpoint has been met · determination of futility during the study, regular monitoring will be conducted to: -confirm adherence to the protocol and applicable guidelines and regulations -ensure adequate recording of data -ensure adequate handling of biological samples and investigational product -verification of informed consent process and withdrawals the study will be supported by funds from each clinical trial site and may receive further support from the public or non-for-profit-private sector. laboratorios rubió has partially contributed to the funding of this project and with the required doses of hydroxychloroquine (dolquine ®). the results of the study will be published as an original article in an international journal. all co-i will be included as co-authors or in the acknowledgements of the article. a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster a novel coronavirus from patients with pneumonia in china world health organization. coronavirus disease 2019 (covid-19) preexposure prophylaxis for the prevention of hiv infection: evidence report and systematic review for the us preventive services task force remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-ncov) in vitro in vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) covid-19: a recommendation to examine the effect of hydroxychloroquine in preventing infection and progression a comparison of sample size methods for the logrank statistic key: cord-316666-qif1k62t authors: ghati, nirmal; roy, ambuj; bhatnagar, sushma; bhati, sumit; bhushan, sudha; mahendran, manjit; thakur, abhishek; tiwari, pawan; dwivedi, tanima; mani, kalaivani; gupta, ritu; mohan, anant; garg, rakesh; saxena, anita; guleria, randeep; deepti, siddharthan title: atorvastatin and aspirin as adjuvant therapy in patients with sars-cov-2 infection: a structured summary of a study protocol for a randomised controlled trial date: 2020-10-30 journal: trials doi: 10.1186/s13063-020-04840-y sha: doc_id: 316666 cord_uid: qif1k62t objectives: to assess the impact of adding statin (atorvastatin) and/or aspirin on clinical deterioration in patients infected with sars-cov-2 who require hospitalisation. the safety of these drugs in covid-19 patients will also be evaluated. trial design: this is a single-centre, prospective, four-arm parallel design, open-label, randomized control trial. participants: the study will be conducted at national cancer institute (nci), jhajjar, haryana, which is a part of all india institute of medical sciences (aiims), new delhi, and has been converted into a dedicated covid-19 management centre since the outbreak of the pandemic. all rt-pcr confirmed cases of sars-cov-2 infection with age ≥ 40 years and < 75 years requiring hospital admission (patients with who clinical improvement ordinal score 3 to 5) will be included in the trial. written informed consent will be taken for all recruited patients. patients with a critical illness (who clinical improvement ordinal score > 5), documented significant liver disease/dysfunction (aspartate transaminase [ast] / alanine aminotransferase [alt] > 240), myopathy and rhabdomyolysis (creatine phosphokinase [cpk] > 5x normal), allergy or intolerance to statins or aspirin, prior statin or aspirin use within 30 days, history of active gastrointestinal bleeding in past three months, coagulopathy, thrombocytopenia (platelet count < 100000/ dl), pregnancy, active breastfeeding, or inability to take oral or nasogastric medications will be excluded. patients refusing to give written consent and taking drugs that are known to have a significant drug interaction with statin or aspirin [including cyclosporine, hiv protease inhibitors, hepatitis c protease inhibitor, telaprevir, fibric acid derivatives (gemfibrozil), niacin, azole antifungals (itraconazole, ketoconazole), clarithromycin and colchicine] will also be excluded from the trial. intervention and comparator: in this study, the benefit and safety of atorvastatin (statin) and/or aspirin as adjuvant therapy will be compared with the control group receiving usual care for management of covid-19. atorvastatin will be prescribed as 40 mg oral tablets once daily for ten days or until discharge, whichever is earlier. the dose of aspirin will be 75 mg once daily for ten days or until discharge, whichever is earlier. all other therapies will be administered according to the institute’s covid-19 treatment protocol and the treating physician’s clinical judgment. main outcomes: all study participants will be prospectively followed up for ten days or until hospital discharge, whichever is longer for outcomes. the primary outcome will be clinical deterioration characterized by progression to who clinical improvement ordinal score ≥ 6 (i.e., endotracheal intubation, non-invasive mechanical ventilation, pressor agents, renal replacement therapy, ecmo requirement, and mortality). the secondary outcomes will be change in serum inflammatory markers (c-reactive protein and interleukin-6), troponin i, and creatine phosphokinase (cpk) from time zero to 5th day of study enrolment or 7th day after symptom onset, whichever is later. other clinical outcomes that will be assessed include progression to acute respiratory distress syndrome (ards), shock, icu admission, length of icu admission, length of hospital admission, and in-hospital mortality. adverse drug effects like myalgia, myopathy, rhabdomyolysis, hepatotoxicity, and bleeding will also be examined in the trial to assess the safety of the interventions. randomisation: the study will use a four-arm parallel-group design. a computer-generated permuted block randomization with mixed block size will be used to randomize the participants in a 1:1:1:1 ratio to group a (atorvastatin with conventional therapy), group b (aspirin with conventional therapy), group c (aspirin + atorvastatin with conventional therapy), and group d (control; only conventional therapy). blinding (masking): the study will be an open-label trial. numbers to be randomised (sample size): as there is no existing study that has evaluated the role of aspirin and atorvastatin in covid-19 patients, formal sample size calculation has not been done. patients satisfying the inclusion and exclusion criteria will be recruited during six months of study period. once the first 200 patients are included in each arm (i.e., total 800 patients), the final sample size calculation will be done on the basis of the interim analysis of the collected data. trial status: the institutional ethical committee has approved the study protocol (protocol version 3.0 [june 2020]). participant recruitment starting date: 28(th) july 2020 participant recruitment ending date: 27(th) january 2021 trial duration: 6 months trial registration: the trial has been prospectively registered in clinical trial registry – india (icmrnims): reference no. ctri/2020/07/026791 (registered on 25 july 2020)]. full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest of expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. supplementary information: the online version contains supplementary material available at 10.1186/s13063-020-04840-y. a series of cases with acute atypical respiratory illnesses was reported from wuhan, china in december 2019. this disease has rapidly spread from wuhan to other areas. the causative agent was found to be a novel coronavirus named as the severe acute respiratory syndrome coronavirus-2 (sars-cov-2, 2019-ncov). the disease was called coronavirus disease 19 (covid-19) and a pandemic was declared by the world health organization (who). covid-19 is rapidly spreading and as of june 14th, 2020, more than 7.8 million cases increased with the severity of the illness. there was increased activation and subsequent exhaustion of cd4+ and cd8+ t cells which has been proposed as a potential contributor to the progression of the disease (2) . the interval between the onset of symptoms and the development of ards has been observed to be as short as 9 days, suggesting a rapid progression of respiratory symptoms in some cases. the disease has a combined case-fatality rate of 2.3% with >430,000 deaths reported globally (3, 4) . a growing number of patients with the severe form of the disease are continuing to succumb worldwide. current treatment is largely supportive with no targeted therapy available. there is an imperative need for the development of antiviral and immunomodulatory drugs that can modify the course of the disease. several drugs including lopinavir-ritonavir, remdesivir, hydroxychloroquine, azithromycin and ivermectin are being evaluate in clinical trials with no promising result so far. this necessitates consideration of the option of adjuvant drug therapy with immunomodulatory and antiviral properties. in this respect, an ideal adjuvant drug should be a low-cost generic medication, easily accessible in pandemics events with an established safety profile. this type of drug should aim at the host's immune response to alleviate the effects of immune dysregulation. such anti-inflammatory and immunomodulatory agents may effectively complement the usual care in covid-19 infection. it is with this premise that we intend to evaluate two commonly used cardioactive drugs with anti-inflammatory properties, statins and aspirin, as adjuvant therapy in covid-19 infection. beyond their hypolipidemic benefits, statins exert multiple cholesterol-independent pharmacological effects (5) . these pleiotropic actions of statins include anti-inflammatory, antioxidant, anti-proliferative and immunomodulatory effects, normalization of sympathetic outflow, and prevention of platelet aggregation. pleiotropy of statins have been proposed to account for the fact that the overall cardiovascular benefits of statins are larger than what one would expect based solely on the reduction in lipid levels. the underlying mechanism for anti-inflammatory actions of statins involves reduction in farnesyl and geranylgeranyl residues as a by-product of inhibition of hmg-coa reductase. these residues are responsible for the correct attachment of different small gtpases to the cell membrane. the blockade of this attachment, gtpase isoprenylation, affects the immune response at multiple levels including t-cell signalling, antigen presentation, immune cell migration and cytokine production. in-vitro studies have shown inhibition of cytokine production including il-6, il-8, and gm-csf by statins, independent of the cholesterol synthesis pathway (6) . il-6 is a pleiotropic cytokine which serves as a critical inflammatory mediator in inflammatory lung diseases. il-6 plays a role in the production of c-reactive protein which is involved in organ dysfunction and death in critically ill patients. in mouse models of endotoxin-induced acute lung injury (ali) to study oxidative stress, statins have been found to significantly reduce levels of redox markers (superoxide dismutase and catalase), the extent of lipid peroxidation (malondialdehyde and hydroperoxides) and myeloperoxidase (7) . the antioxidant effects of statins also relate to their ability to inhibit the production of isoprenoid compounds via the mevalonate pathway and consequential downregulation of redox-sensitive proinflammatory transcriptional factors such as nf-κb. based on these pleiotropic effects, statins have been evaluated as an immunomodulatory agent in bacterial and viral pneumonias. observational studies have shown that prior therapy with statins may be associated with a reduced rate of severe sepsis and icu admission in patients with acute bacterial infections (8, 9) . a large population-based, retrospective study showed that patients on statins had a significantly reduced risk of fatal pneumonia and slightly but not significantly reduced risks of uncomplicated pneumonia and pneumonia hospitalization with survival. a randomised comparison of pravastatin with a placebo (n=44) for reducing ventilator-associated pneumonia (vap) in patients on mechanical ventilation and intensive care unit stay of >48 hours showed an indication for increased probability of being free from vap during the 30-day treatment period in the pravastatin group (10). on the contrary, another randomised study failed to show a benefit on 28-day survival of addition of simvastatin in adults with suspected vap (11) . the observations are more promising in viral pneumonias. a summary of studies on use of statins in in-vitro and murine models of viral pneumonias is provided in table 1 . a recently completed randomised controlled trial (clinicaltrials.gov number, nct02056340) showed a significant improvement of symptoms in statin-naïve patients hospitalized for seasonal influenza receiving atorvastatin compared with placebo. specific to coronaviruses, statins have some actions that might be especially beneficial. sars-cov-1 interacts with toll-like receptors on the host cell membrane and significantly induces the expression of the myd88 gene (12) . downstream effects of this include activation of the nf-kb pathway and severe inflammation, a hallmark of covid-19 infection. statins have been shown to stabilize myd88 levels after a proinflammatory trigger in experimental models, thereby attenuating the inflammatory response (13) . a second theoretical anti-coronavirus action of statins involves interference with ace2 signalling. sars-cov-2 utilizes ace2 for initial entry and then down-regulates ace2 expression. this action possibly facilitates the initial influx of innate immunity cells, causing an unopposed angiotensin ii accumulation and consequent organ injury (14) . statins are known to experimentally up-regulate ace2 via epigenetic modifications (15) . since an increase in ace2 might prove beneficial for covid-19 patients, there is biological plausibility to investigate statins in decreasing the severity of covid-19 infection. aspirin or acetylsalicylic acid (asa) is one of the most commonly used anti-platelet drug for the prevention of myocardial infarction, stroke, cardiac stent thrombosis, and bypass graft protection. it irreversibly inhibits platelet cyclooxygenase 1 and 2 (cox-1/-2) enzymes. this results in decreased synthesis of thromboxane a2 leading to an inhibitory effect on platelet aggregation (24, 25). in addition to its anti-platelet effects, aspirin has also been used as an anti-inflammatory drug in several immune-mediated diseases (e.g., acute rheumatic fever) (26). few in-vitro studies have also proposed an anti-viral property of aspirin against several viruses like-hepatitis c (27,28), varicella zoster (29), cytomegalovirus (30), influenza a virus (31) . though the exact mechanism behind its anti-inflammatory and anti-viral action is still unknown, several hypotheses have been proposed (32) -first, aspirin causes uncoupling of oxidative phosphorylation in hepatic mitochondria (33) ; second, it induces no radicals responsible for a decrease in inflammation (34); third, it modulates signalling through transcription factor nf-kb which play central role in many biological processes including systemic inflammation. in addition, aspirin modulates claudin-1 receptor in host cell membrane inhibiting hepatitis c virus entry (35) . one in-vivo experiment with influenza a virus has also suggested aspirin's anti-viral action through its influence on the nf-kb pathway (36) . aspirin is one of the potential drugs that are being tested in multiple ongoing trials including one large rct (clinicaltrials.gov, nct0433340), as an adjuvant anti-inflammatory, anti-viral, and anti-platelet therapy against sars-cov-2 virus infection. recent electron microscopic and immunohistochemical evidence has suggested an elevated number of megakaryocytes and platelet-rich thrombi in alveolar capillaries from lung tissue of deceased patients with severe covid-19 infection (37) . aspirin may inhibit the formation of platelet rich thrombi leading to an improvement in pulmonary regional ventilation-perfusion mismatch. subsequent decrease in the alveolar capillary membrane thickness may also improve oxygen diffusion capacity and oxygen saturation in patients with ards due to severe covid-19 infection (38, 39) . till date there is only one case control study (39) that evaluated the benefit of adding antiplatelet agents in addition to the prophylactic anticoagulants in the management protocol of severe covid-19 infection. in that study, tirofiban infusion followed by aspirin and clopidogrel combination for 30 days resulted in significant improvement in a-a o2 gradient in covid-19 patients with severe hypoxemia. moreover, there was a significant improvement in ards resulting in weaning from cpap therapy in patients who received antiplatelet agents. however, the current evidences on aspirin is very scarce to either support or defy its regular use in the management of covid-19 infected patients. patients satisfying the inclusion and inclusion criteria will be recruited in the study during six months of study period. once first 200 patients are included in each arm (i.e., total 800 patients), final sample size calculation will be done on the basis of the interim analysis of the collected data. the study will be conducted at the national cancer institute (nci), jhajjar, haryana, which is a part of the all india institute of medical sciences (aiims), new delhi, and has been converted into a dedicated covid-19 management centre since the outbreak of the pandemic. all sars-cov-19 infected patients requiring admission in the study centre will be screened for the trial. inclusion criteria: • age ³ 40 years, < 75 years • critical illness with who clinical improvement ordinal score > 5 • documented significant liver disease / dysfunction (ast/alt > 240) • myopathy and rhabdomyolysis (cpk > 5x normal) • allergy or intolerance to statins • allergy or intolerance to aspirin • patients taking the following medications: cyclosporine, hiv protease inhibitors, hepatitis c protease inhibitor, telaprevir, fibric acid derivatives (gemfibrozil), niacin, azole antifungals (itraconazole, ketoconazole) clarithromycin and colchicine • prior statin use (within 30 days) • prior aspirin use (within 30 days) • history of active gi bleeding in past three months • coagulopathy • thrombocytopenia (platelet count < 100000/ dl) • pregnancy, active breast-feeding • patient unable to take oral or nasogastric medications all confirmed (rt-pcr) and mild-moderately symptomatic cases of sars-cov-19 infection requiring admission in the national cancer institute (nci), jhajjar, haryana will be screened for recruitment. the patients will be managed according to the institute treatment protocol (appendix -iii). demographic information, including age, gender, residential address, bmi will be recorded in a structured proforma ( table 2 and appendix-i). all patients will be clinically evaluated for comorbidities (e.g., diabetes mellitus, hypertension, coronary artery disease, heart failure, ischemic stroke, chronic kidney disease, chronic liver disease, etc.), chronic medication history, covid-19 related symptoms and signs (e.g., fever, cough, sore throat, dyspnea, body ache, etc.). routine investigations like chest x-ray, 12-lead electrocardiography (ecg), complete blood count, liver function test, renal function test, fasting blood sugar-will be documented at baseline. the study will use a four-arm parallel group design. a computer-generated permutated block randomization with mixed block size will be used to randomize the participants in a 1:1:1:1 ratio to the group a (atorvastatin with conventional therapy), group b (aspirin with conventional therapy), group c (aspirin + atorvastatin with conventional therapy), and group d (control; only conventional therapy). atorvastatin will be prescribed as 40mg oral tablets once daily for 10 days or until discharge whichever is earlier. aspirin dose will be 75mg once daily for 10 days or until discharge whichever is earlier. all study participants will be prospectively followed up for ten days or until hospital discharge whichever is longer for outcomes. patients with early discharge (due to clinical improvement and patient's preference for home isolation) will be followed up by alternate day telephonic contact till 10 th day of drug regimen. serum cpk, lft, trop -i, serum inflammatory biomarkers -i.e., crp, and il-6 will be repeated on 5th day of study enrolment or 7th day after symptom onset, whichever is later. decision regarding other medications and investigation will be based on institute management protocol and treating physician's clinical judgement. the quantitative variables will be summarized through descriptive statistics, i.e., mean (±sd) or interquartile range, and the categorical variables will be summarized through frequency (%). both intention-to-treat (itt) and per protocol (pp) analysis will be carried out for primary and secondary outcomes. the primary outcome will be compared between the groups using proportions test. serum inflammatory markers will be test for normality assumption using shapiro-wilks test. variables that follow normal distribution will be compared between the groups over a period of time using generalized estimating equation and those variables that do not follow normal will be analyzed using wilcoxon rank sum test and wilcoxon signed rank test. other outcomes (time-to-event) will be compared using kaplan-meier curve and log-rank test. the cox proportional hazards model will be used to calculate hazards ratio and 95% confidence interval. safety outcomes will be compared between the groups using chi-square or fisher's exact test. two-sided p value <0.05 will be considered significant. the data will be assessed using stata statistical software. widely used in prevention of heart and brain attacks. these two drugs are being studied in covid-19 patients all over the world due to their encouraging anti-viral and anti-inflammatory actions that may prevent lung complications and serious outcomes including death. there is currently very little data available on their efficacy and safety in covid-19 patients. this research is being done to assess the utility and safety of atorvastatin (statin) and aspirin in covid-19 patients. this study will help to learn whether these widely available medicines are useful or not in management and preventing complications of covid-19 patients. if you consent, you will be enrolled as a subject in the study during your hospital admission. the doctor will take brief history followed by focused physical examination. then you will be allotted to one of the four groups i.e., group a (will receive atorvastatin tablet), group b (will receive aspirin tablet), group c (will receive both aspirin tablet and atorvastatin tablet), group d (will receive only conventional therapy). the allotment will be done randomly with the help of a computer -not by your or investigator's choice. the decision to prescribe other conventional medicines, as well as all other aspects of your treatment will be decided by your treating doctor as per aiims protocol and will not be affected by your taking part in this study. approx. 10 ml of blood (about 2 teaspoon) will be drawn on the day of enrolment for routine blood tests like complete blood count, kidney function test, liver function test, lipid profile etc. which will be helpful for both the disease management and the research. aspirin and atorvastatin will be given for ten days or till your discharge whichever is later. you will be followed up for ten days or till discharge, whichever is later, during which repeat blood tests will be done on 5 th day (for trial) and as required for your treatment. as mentioned above the duration of the study would be ten days or till your discharge whichever is earlier. in order to preserve your confidentiality only an anonymous subject number will be associated with the information you provide. your name will not appear on any publication or be released to anyone without your written consent. your anonymised records will be kept secured and confidential. the drugs being tested in the trial will be provided free of cost. also, the blood tests to be done as part of this research project will be performed free of cost. both atorvastatin and aspirin are time-tested and safe drugs. atorvastatin has been used to lower bad cholesterol (ldl), prevent heart attack, brain attack; and aspirin to prevent heart attack, stroke and protect stents and bypass grafts in enumerable patients without any major safety concerns. atorvastatin can very rarely cause muscle pain, muscle injury, muscle breakdown (0.005-0.01%), and liver dysfunction (0.5-1%). however, most of these sideeffects occur with prolonged use. the probability of these side-effects with 10-day use is very low. aspirin may also result in allergies (2.5%) and major bleeding (0.05%). however, the probability at low dose and with ten days use is again extremely low. during the study we will closely monitor you for these side-effects and will immediately stop the drugs when necessary. appropriate treatment will be provided at our hospital in the extremely unlikely situation that any of these side-effects occur. the investigations needed for the study are benign and do not have any potential to cause harm to the patient. your participation will help us to assess the role of aspirin and atorvastatin in preventing complications like acute respiratory distress syndrome (ards), shock (severely low blood pressure), and other covid-19 related major complications. this information will help in creating an effective and safe management strategy for covid-19 patients in future. appropriate treatment free of cost will be provided at our hospital, aiims, new delhi in the extremely unlikely situation that any of the above-mentioned side-effects occur. however, this being an investigator led academic study no compensation will be provided in the very unlikely treatment related disability or death arising out of the study. your participation in the study is completely voluntary. choosing not to participate will not affect treatment services you may be eligible for now or in the future. you can also leave the study at any time without giving any reason if you wish to. this would not lead to any penalty or loss of benefit to you as a patient of this hospital. you can ask questions about this project at any time. you may contact the investigators given below, if you have any questions or grievances about this research study. please feel free to ask about anything you do not understand. please read and review this research and patient information form carefully before you agree to participate. you may take as much time as you need to think over it. the content of information sheet dated ________ (version) ___________ that was provided have been read carefully by me/explained to me in detail, in a language that i comprehend and i have fully understood the contents. i confirm that i have had opportunity to ask questions. the nature and purpose of study and its potential risks/ benefits and expected duration of study, and relevant details of study have been explained to me in detail. i understand that my participation is voluntary and that i am free to withdraw at any time without giving any reasons, without my medical care or legal rights being affected. i understand that the information collected about me from my participation in this research and sections of any of my medical notes may be looked at by responsible individuals from aiims. i give permission for these individuals to have access to my records. i agree to take part in the above study. functional exhaustion of antiviral lymphocytes in covid-19 patients characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72314 cases from the chinese center for disease control and prevention case-fatality rate and characteristics of patients dying in relation to covid-19 in italy clinical implications for statin pleiotropy. current opinion in lipidology inhibitory effect of statins on inflammatory cytokine production from human bronchial epithelial cells redox markers and inflammation are differentially affected by atorvastatin, pravastatin or simvastatin administered before endotoxin-induced acute lung injury effect of pravastatin on the frequency of ventilator-associated pneumonia and on intensive care unit mortality: open-label, randomized study effect of statin therapy on mortality in patients with ventilator-associated pneumonia: a randomized clinical trial toll-like receptor 3 signaling via trif contributes to a protective innate immune response to severe acute respiratory syndrome coronavirus infection atorvastatin attenuates myocardial remodeling induced by chronic intermittent hypoxia in rats: partly involvement of tlr-4/myd88 pathway. biochemical and biophysical research communications potential effects of coronaviruses on the cardiovascular system: a review hiding in plain sight: an approach to treating patients with severe covid-19 infection statins block influenza infection by down-regulating rho/rho kinase pathway statins reduce the expression of proinflammatory cytokines in influenza a virus infected crfk cells simvastatin suppresses rantes-mediated neutrophilia in polyinosinic-polycytidylic acid-induced pneumonia acetylsalicylic acid inhibits hepatitis c virus rna and protein expression through cyclooxygenase 2 signaling pathways in vitro activity of acetylsalicylic acid on replication of varicella-zoster virus aspirin attenuates cytomegalovirus infectivity and gene expression mediated by cyclooxygenase-2 in coronary artery smooth muscle cells anti-influenza viral activity of aspirin in cell culture antiviral activity of aspirin against rna viruses of the respiratory tract-an in vitro study. influenza other respir viruses uncoupling of intestinal mitochondrial oxidative phosphorylation and inhibition of cyclooxygenase are required for the development of nsaid-enteropathy in the rat 15-epi-lipoxin a4-mediated induction of nitric oxide explains how aspirin inhibits acute inflammation aspirin inhibits hepatitis c virus entry by downregulating claudin-1 acetylsalicylic acid (asa) blocks influenza virus propagation via its nf-kappabinhibiting activity pulmonary post-mortem findings in a series of covid-19 cases from northern italy: a two-centre descriptive study. the lancet infectious diseases gas exchange and ventilation-perfusion relationships in the lung enhanced platelet inhibition treatment improves hypoxemia in patients with severe covid-19 and hypercoagulability. a case control, proof of concept study key: cord-288344-8dar2p3j authors: yang, xiaoyu; huang, junjun; hu, yan; guo, cuiyan; wang, xi; yang, zhao; zhou, tianyu; wang, guangfa title: the rescue intervention strategy for asthma patients under severe air pollution: a protocol for a single-centre prospective randomized controlled trial date: 2020-11-04 journal: trials doi: 10.1186/s13063-020-04830-0 sha: doc_id: 288344 cord_uid: 8dar2p3j background: asthma is a common chronic airway inflammatory disease. exacerbations of asthma not only accelerate the progression of the disease but also increase the incidence of hospitalization and death. studies have shown that air pollution is a high-risk factor for asthma exacerbations. however, few treatment strategies have been recommended to reduce the risk of severe air pollution-related asthma exacerbations. methods/design: this is a single-centre, prospective, randomized and standard treatment parallel control clinical trial. seventy-two asthma patients in the nonexacerbation stage according to gina guidelines 2017 will be recruited and randomized into the rescue intervention strategy (ris) group and control group. original treatments for the participants will include no use of inhaled medicine, the use of short-acting β-agonists (saba) on demand or the use of budesonide/formoterol (160 μg/4.5 μg/dose, 1–2 dose/time, b.i.d.). the rescue intervention strategy for the ris group will be budesonide/formoterol plus the original treatment until the severe pollution ends (air quality index, aqi < 200). the control group will maintain the original treatment. the follow-up observation period will last 1 year. the primary outcome is the frequency of asthma exacerbations per year. secondary outcomes include the mean number of unplanned outpatient visits, emergency visits, hospitalizations, medical costs and mortality caused by asthma exacerbations per patient per year. discussion: the results of this trial will provide a novel strategy to guide clinical practice in decreasing the risk of asthma exacerbations under severe air pollution. trial registration: chictr chictr1900026757. registered on 20 october 2019—retrospectively registered recently, increasing attention has been drawn to air pollution and its serious consequences, especially in china and other developing countries. the evidence has demonstrated that air pollution could cause critical public health problems. a retrospective study of 80,515 deaths in beijing during 2004-2008 found that the reduction in life expectancy was associated with increased air pollution. more specifically, an interquartile range increase in particulate matter with aerodynamic diameter < 2.5 μm (pm 2.5 ), pm 10 , so 2 and no 2 was associated with 15.8, 15.8, 16.2 and 15.1 years of life lost, respectively [1] . asthma is a common chronic airway inflammatory disease, with more than 45 million adults suffering from asthma in china [2] . exacerbations of asthma not only accelerate the progression of the disease but also increase the incidence of hospitalization and death. it has already been proven that air pollution can cause asthma exacerbations [3] . unfortunately, few treatment strategies have been recommended to reduce severe air pollution-related asthma exacerbations. inhaled corticosteroids (ics)/long-acting β-agonists (laba) with single maintenance and relief therapy (smart) are well known for significantly reducing asthma exacerbations [4] . however, only when patients have symptoms will smart be applied, meaning that the airways have already been damaged by atmospheric pollutants and the subsequent inflammatory response. some treatments with ics/laba (such as budesonide/formoterol) might stop these inflammatory responses with rapid action [5] . therefore, we hypothesize that the rescue intervention strategy of budesonide/formoterol plus original treatments under severe pollution may reduce the risk of asthma exacerbations caused by air pollution before patients have symptoms. we will undergo a 1.5-year single-centre prospective randomized controlled clinical trial to compare the frequency of asthma exacerbations per year and asthma exacerbation-related visits, hospitalizations, mortality, medical costs etc. between the rescue intervention strategy (ris) group and the control group. this study is a single-centre, prospective, randomized and standard treatment parallel control clinical trial (see fig. 1 ). we followed the standardized programme intervention: standard protocol item recommendations for interventional trials (spirit) 2013. we followed similar methods of zhou et al. 2019 [6] , especially in the 'intervention' and 'outcomes' sections. patients who meet the inclusion criteria (details are shown in the 'inclusion criteria' section) and do not meet the exclusion criteria (details are shown in the 'exclusion criteria' section) will be recruited from peking university first hospital. advertising strategies such as posters, social media and popular community websites will be used to increase recruitment. when screening, the purposes, procedures, potential benefits and risks of the study will be explained carefully by the investigators. after explaining the trial, the investigators will answer any questions that the participants may have about the study. participants will then make the final decision on whether to participate and sign the informed consent form. then, written informed consent will be obtained, and each participant visit will be overseen by a trained clinician. at the baseline visit (v0), basic data will be collected, including sex, age, education, income, type of medical insurance, workplace/home addresses, the air pollution monitoring station for the study (which is defined as the nearest air pollution monitoring station from the workplace for employees or from home for nonemployees), medical/surgical history, suspected allergen contact history (such as pets), therapeutic scheme for asthma and any exacerbations experienced within the past 3 months. physical examinations will also be performed (height, weight, body mass index (bmi), heart rate and blood pressure), along with the chinese version of asthma assessment scales, which have shown good validity [7] (the mini asthma quality of life questionnaire 7 (mini-aqlq 7), the numerical control questionnaire (acq) and asthma control test (act)), lung function testing (bronchodilator reversibility test) and fraction of exhaled nitric oxide (feno) measurement, which will be interpreted with the use of cut points. several interventions, such as no use of inhaled medication, the use of saba on demand or the use of budesonide/formoterol (160 μg/4.5 μg/dose, 1-2 dose/time, b.i.d.), are acceptable as the original treatment in our study. participants receiving other treatments must enter a washout period (see table 1 ). thereafter, they will be fig. 1 the study design flowchart (*ris group, rescue intervention strategy group) randomly divided into two groups: the ris group and the control group. exacerbation situations within the past 3 months, physical examinations, asthma assessment scales, lung function tests (bronchodilator reversibility tests) and feno measurements will be repeated on the randomization day (v1). when the air quality index (aqi) reported by the air pollution monitoring station for the study is no less than 200, participants in the ris group will receive budesonide/formoterol (160 μg/4.5 μg/dose, 1 dose/time, b.i.d.) plus original treatments until the end of severe pollution (aqi < 200). at the same time, participants in the control group will continue to receive the original treatment. participants will visit peking university first hospital every 3 months and will be followed up for 1 year (v2-v5). at each visit, exacerbations within the past 3 months, physical examinations, asthma assessment scales and lung function tests (bronchodilator reversibility tests) will be repeated. feno measurements will be repeated only at the final visit (v5). the inclusion criteria were as follows: (1) age between 18 and 80 years old (male or female), (2) asthma patients at the nonexacerbation stage (according to gina guidelines 2017), (3) smoking cessation for more than or equal to 6 months or no smoking history, (4) no restrictions in performing daily activities, (5) a resident of beijing (employees should make sure that there are air pollution monitoring stations within 5 km of their workplace, and nonemployees should make sure that there are air pollution monitoring stations within 5 km of their home), (6) a smartphone available at their disposal, (7) willing to provide written informed consent and (8) willing to follow the research programme. the exclusion criteria were as follows: (1) diagnosis of another chronic respiratory diseases, such as chronic obstructive pulmonary disease, lung cancer, tuberculosis, bronchiectasis and diffuse lung disease (interstitial pneumonia, occupational lung disease, sarcoidosis etc.); (2) a history of lobectomy, lung transplantation or pleural disease; (3) severe underlying disease (including severe psychiatric disorders, dysgnosia, nervous system disease, other malignant tumour, chronic liver disease, heart failure, autoimmune disease and chronic kidney disease); (4) life expectancy of less than 3 years; (5) no participation in outdoor activities; (6) expecting to move out of beijing within 2 years; (7) planning to decorate home or workplace during the research period; (8) alcohol or substance abuse; (9) allergy history or other contraindication against the medicine used in this trial; (10) participating in other clinical trials; (11) poor compliance; (12) unwilling to provide written informed consent; (13) diagnosis of osteoporosis or diabetes due to the risk of adverse effects related to the use of budesonide/formoterol; and (14) cigarette smoking more than or equal to 10 pack-years. to estimate compliance before the start of the study, investigators will describe the process of our study in detail and emphasize the long-term follow-up when screening. patients will answer three questions with 'yes' or 'no'. the questions are 'over the past two weeks, were there any days when you forgot to take your asthma medicine?', 'taking medication every day is a real inconvenience for some people. do you ever feel hassled about sticking to your asthma treatment plan?' and 'do you have difficulty remembering to take all your asthma medication?'. if the answers are all 'yes', the patient's compliance will be assessed as poor. block randomization will be used to generate random codes. the random codes will be designed in a 1:1 ratio (ris group or control group) using the sas 9.2 software package (sas institute, cary, nc). a researcher who is not participating in this study will generate random codes and make random grouping envelopes based on the generated results. the envelopes will be sealed and handed to the researcher responsible for grouping. after screening, participants will be identified by subject numbers according to the sequence in which they enter this trial. when grouping, the envelope with the corresponding number for the subject number of the participant for 4 weeks saba short-acting β-agonists, laba long-acting β-agonists, ics inhaled corticosteroids will be opened. the participant will be assigned to the ris group or the control group according to the randomization result in the envelope. the randomization result will be just told to the participant and researchers responsible for grouping and intervention, then it will be resealed in the same envelope until the end of the study. after randomization and grouping, all participants will be asked to add wechat (a popular social app provided by tencent company, china) friends with the intervention clinician. the communications between participants and the intervention clinician will be mainly through the wechat app. the data in this app will be saved and backed up. the real-time aqi will be collected from the beijing air pollution app (provided by the beijing municipal environmental monitoring center, china). the intervention clinician will send the real-time aqi from the air pollution monitoring station for the study to each participant via wechat between 9 am and 10 am every day. when the aqi is no less than 200, the intervention clinician will ask the participants in the ris group to take budesonide/formoterol (160 μg/4.5 μg/dose, 1 dose/ time, b.i.d.) plus the original treatment until severe pollution ends (aqi < 200), as indicated by wechat. these participants will reply to the intervention message as a confirmation via wechat. at the same time, the control group will be asked to focus on protective strategies (avoid outdoor activities, for example) and maintain their original treatments. the follow-up observation period will last 1 year. daily aqi and whether the intervention is successfully accomplished during every intervention period will be recorded by wechat, and investigators will have a backup copy of these data. when participants need to visit the hospital to receive medicine for asthma or due to respiratory symptoms, they will be asked to visit with the intervention clinician. then, the intervention clinician will assign a clinician from our study who is working at peking university first hospital that day to provide medical services to the participants. medical records will be completed and saved in the medical record system of peking university first hospital. the completed medical records will be printed immediately to preserve the data. if the participants visit another hospital for an emergency, the medical records of this visited hospital will be photographed or scanned by the intervention clinician to preserve the data. participants will be requested to visit peking university first hospital every 3 months for 1 year (v2-v5). at each visit, exacerbations within the past 3 months, physical examinations, asthma assessment scales and lung function tests (bronchodilator reversibility tests) will be repeated. feno measurement will be repeated only at the final visit (v5). exacerbation situations will include moderate exacerbations (which are defined as the use of relief therapy for more than 2 days) and severe exacerbations (which are defined as the occurrence of unplanned outpatient visits, emergency visits and hospitalizations). the exacerbation situation will be verified by medical records from peking university first hospital and other hospitals. all these visits (v0-v5) and data will be recorded in the case report form (crf). details of the follow-up visits are shown in table 2 . the crf is designed by the study staff. double data entry and periodic auditing will improve data quality and integrity. personal information and related documents of all participants will be kept strictly confidential. every participant will be identified by a subject number and a name acronym in the crf. all researchers taking part in this clinical study will receive systemic training before patient enrolment. throughout the study, the researchers responsible for the interventions and for randomization and grouping will be separated from the other researchers. as a result, the others (who will be responsible for providing medical service and measuring asthma assessment scales, for example) will be blinded to the study grouping. data analysts will also be blinded. the data will be labelled 'group a' or 'group b' when data analysis is performed. the primary outcome is the frequency of asthma exacerbations per year, which is defined as the mean number of asthma exacerbations per patient per year at the end of the 1-year follow-up period. asthma exacerbation situations include moderate exacerbations (defined as the use of relief therapy for more than 2 days) and severe exacerbations (defined as the occurrence of unplanned outpatient visits, emergency visits and hospitalizations). the secondary outcomes include the mean number of unplanned outpatient visits, emergency visits, hospitalizations, medical costs and mortality caused by asthma exacerbations per patient per year at the end of the 1year follow-up period. adverse events are unforeseeable and unfortunate events that occur during a study, either occurring with or without the intervention. although the medicine used in our study is within the recommended dosage, adverse events may still occur during daily use. nonsystematically via spontaneous self-report will be used to collect adverse events. all adverse events will be carefully monitored, managed and tracked in a timely manner until they are properly resolved, stabilized or returned to normal. the occurrence of adverse events will be recorded from the beginning to the end of the study. there will be supervisors who come from the administrators of peking university first hospital. all adverse events will be reported to these supervisors. if there are any severe adverse events, they will be reported immediately to the peking university first hospital institutional review board (irb). severe adverse events will be analysed every 3 months during the study by supervisors and the irb. if there is a definite benefit (p < 0.01) or an obvious disadvantage (p ≤ 0.05), the study will be stopped after the discussion of the centre and the approval of the ethics committee. according to a previous study, every increase in pm 2.5 of 10 μg/m 3 increased asthma-related outpatient visits by 0.65% and emergency visits by 0.49% in beijing [8] . every increase in pm 10 of 10 μg/m 3 increased the incidence of asthma exacerbations by 3-6% [9] . the beijing environmental statement published in 2016 by the beijing environmental protection agency showed that the monthly mean concentration grew from approximately 70 to 150 μg/ m 3 of pm 10 and 52 to 150 μg/m 3 of pm 2.5 [10] . this means that the risk of asthma exacerbations increases by at least 30% as air pollution changes. assuming an exacerbation frequency rate ratio (rr) of 0.85 in the ris group compared to the control group, a total of 60 subjects (30 in each group) are required to detect a 75% reduction in air pollution-related exacerbation at 90% power with a two-sided significance level of 0.05. we recruited a total of 72 subjects considering a dropout rate of 20%. statistical analysis will be carried out using spss 14.0 software (international business machines corp., new york, usa). all statistical analyses will be performed by the two-sided test. p values < 0.05 will be considered statistically significant (unless otherwise specified). the poisson regression model will be used to calculate the 95% confidence interval and the rr of exacerbation frequency. numeric variables will be presented as the mean (standard deviation) or median (minimum, maximum; or interquartile range), and categorical variables will be presented as the number of cases (percentage). the data will be analysed by the independent sample t test, the wilcoxon rank sum test, the chi-square test, the continuity corrected chi-square test or fisher's exact test. the characteristics of the baseline will be summarized by the equilibrium test. unplanned outpatient visits, emergency visits, hospitalizations, medical costs and mortality caused by asthma exacerbations per year will be compared between the two groups. we have no imputation plans for missing data. the population of intention-to-treat analysis is defined as participants who have completed randomization. the population of perprotocol analysis is defined as participants who have strictly observed the intervention protocol and completed the follow-up. the population of safe set analysis is defined as participants who have completed randomization. we have no plans to conduct a modified intention-to-treat analysis. this study proposes a rescue intervention strategy for asthma patients under severe air pollution. this singlecentre, prospective, randomized and standard treatment parallel control clinical trial aimed to determine whether the rescue intervention strategy will reduce the risk of air pollution-related asthma exacerbations. ics and laba are highly recommended by gina for asthma patients [11] . ics is regarded as the most important and effective drug for asthma control, although a high dose of ics may increase the risk of pneumonia. compared with salmeterol/fluticasone, a recent study showed that budesonide/formoterol had a lower risk of adverse events [12] . jenkins et al. demonstrated that high-dose budesonide/formoterol (1280 μg/36 μg/day) was effective and well tolerated in asthma patients [13] . in our study, the rescue intervention strategy used is budesonide/formoterol (160 μg/4.5 μg/dose, 1 dose/time, b.i.d.) plus the original treatment until severe pollution ends (aqi < 200). the maximal dosage of budesonide/ formoterol per day in our study is less than the dosage used in jenkins' research. budesonide/formoterol shows rapid-acting effects in asthma and can be used in single inhalers for maintenance and relief therapy [14] . the smart study reported that receiving budesonide/formoterol might significantly reduce the risk of asthma exacerbations [4] . as a result, budesonide/formoterol is believed to be an ideal rescue intervention drug and might be safe as an addition to the original treatment. to decrease the effects of different inhaled drugs, the original treatment for the participants in our study will be selected from the following: no use of inhaled medication, the use of saba on demand or the use of budesonide/formoterol (160 μg/4.5 μg/dose, 1-2 dose/time, b.i.d.). in our study, the rescue intervention strategy is to be administered until the end of severe pollution (aqi < 200). however, an aqi of 151-200 is moderate air pollution, and an aqi of 101-150 is slight air pollution. in 2018, the number of days with an aqi ≥ 100 was 138 days (37.8%), and the number of days with an aqi ≥ 200 was 15 days (4.1%) in beijing [15] . if we take the aqi as < 100, there will be more than 100 intervention days. a recent study suggested a possible association between respiratory tract infection and the use of ics in asthma patients [16] . as a result, the strategy we used will decrease the dosage of ics to reduce the infection risk. the article by zhou et al. 2019 [6] is a protocol for a chronic obstructive pulmonary disease (copd)-associated study that is being led by our department (department of respiratory and critical care medicine, peking university first hospital). these two studies share some of the same research members, such as guangfa wang and tianyu zhou. however, the assessment scales, therapeutic replacement schemes for the washout period, inclusion and exclusion criteria, randomization, grouping etc. are suitable for asthma and single-centre studies but not for copd and multicentre studies. moreover, there are several differences between these two studies in terms of the intervention used. first, our study uses real-time aqi instead of 24-h mean aqi, and the rescue intervention strategy of our study will be performed until the end of severe pollution (aqi < 200) instead of the third day after the end. the heart study found that air pollution led to a delayed inflammatory burst in the lung that lasted almost 3 days, and airway inflammation in copd patients worsened after exposure to severe air pollution [17] [18] [19] . nevertheless, our study uses real-time aqi, and the intervention programme may be started within the first few hours of when severe air pollution begins. this strategy might stop the inflammatory responses in an early stage to protect airways against damage from atmospheric pollutants. moreover, a possible association between respiratory tract infection and the use of ics in asthma patients has been reported [16] . our strategy will decrease the dosage of ics to reduce the risk of respiratory infection. second, communication between the participants and intervention researchers will mainly occur through wechat. wechat is the most popular social app in china [20] . the use of wechat is both customary (to improve the compliance of participants) and objective (to ensure the authenticity of the data). the limitations of our study are as follows. first, the study does not follow a double-blind design because participants in the control group will not be administered a placebo. to decrease the potential bias, there are independent groups of researchers responsible for the intervention and for randomization and grouping. the other researchers (who are responsible for providing medical service and measuring asthma assessment scales at the follow-up visits, for example) will be blinded to the grouping results. second, the study was not a multicentre design and was performed only in beijing. thus, selection bias cannot be avoided. this is a single-centre, prospective, randomized and standard treatment parallel control study aimed at decreasing the risk of asthma exacerbations under severe air pollution with a novel rescue intervention strategy. this document is based on version 1.2 (11 november 2018) of the study protocol. the recruitment has finished (from 1 january 2019 to 30 june 2019), and the trial is currently at the stage of participant follow-up visits and data collection (from 1 january 2019 to 30 june 2020). the burden of air pollution on years of life lost in beijing, china, 2004-08: retrospective regression analysis of daily deaths prevalence, risk factors, and management of asthma in china: a national cross-sectional study association between air pollution and asthma exacerbations in badalona association of inhale corticosteroids and long-acting β-agonists as controller and quick relief therapy with exacerbations and symptom control in persistent asthma a systematic review and meta-analysis understanding how long-acting β2-adrenoceptor agonists enhance the clinical efficacy of inhaled corticosteroids in asthmaan update a prospective study of salvational intervention with ics/laba for reducing chronic obstructive pulmonary disease exacerbation under severe air pollution (sircap) in beijing: protocol of a multi-center randomized controlled trial validity of a chinese version of the mini asthma quality of life questionnaire (miniaqlq) and a comparison of completion by patients and relatives fine particulate air pollution and hospital visits for asthma in beijing short-term effects of pm 10 and no2 on respiratory health among children with asthma or asthma-like symptoms: a systematic review and meta-analysis beijing environmental statement global initiative for asthma. from the global strategy for asthma management and prevention (gina pneumonia and pneumonia related mortality in patients with copd treated with fixed combinations of inhaled corticosteroid and long acting beta2 agonist: observational matched cohort study (pathos) efficacy and safety of high-dose budesonide/formoterol (symbicort) compared with budesonide administered either concomitantly with formoterol or alone in patients with persistent symptomatic asthma single-inhaler combination therapy for maintenance and relief of asthma: a new strategy in disease management ambient air quality of beijing in december inhaled corticosteroids and risk of upper respiratory tract infection in patients with asthma: a meta-analysis inflammatory and oxidative stress responses of healthy young adults to changes in air quality during the beijing olympics association between exposure to ambient particulate matter and chronic obstructive pulmonary disease: results from a cross-sectional study in china copd exacerbations: defining their cause and prevention development report on china's wechat in publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations authors' contributions xy is a joint first author. jh obtained funding. gw and jh are the joint corresponding authors. gw and jh conceived and designed the study. jh, xy, yh and tz drafted the protocol. jh, xy and yh collected the data. jh, xy, cg and xw were responsible for data management and performed the statistical analysis. zy was responsible for administrative management. all authors read and approved the final manuscript and are responsible for their contributions. this study is supported by grant 2018cr02 from the youth clinical research project of peking university first hospital. the funding bodies do not participate in the design of the study or in the collection, analysis and interpretation of data. in addition, the funding bodies do not participate in writing the manuscript. data sharing is not applicable to this article, as no datasets were generated or analysed during the current study. when the trial is completed, we plan to publish the results in a peer-reviewed journal article. the data from the trial will be available by request with privacy protection (contact with junjun huang, jaglpc@126.com). the first version of the study protocol was approved by the peking university first hospital institutional review board (irb) (2018[268]) in december of 2018. any protocol modifications will be submitted for the irb review and approval. to reduce the risk of infected covid-19, the follow-up visits were changed to online visits by wechat during the pandemic period. for each online visit, data regarding any exacerbations experienced during the past 3 months will still be collected, and the asthma assessment scales will still be conducted. however, the data from the physical examinations, lung function tests (bronchodilator reversibility tests) and feno measurements will be missed. these modifications to the protocol have been approved by the peking university first hospital irb. the study will be conducted in accordance with good clinical practice (gcp) requirements and ethical principles outlined in the declaration of helsinki. the purposes, procedures, and potential benefits and risks of the study will be explained carefully by investigators with written informed consent. written informed consent will be obtained from each participant. personal information and related documents of all participants will be kept strictly confidential. every participant will be identified by a subject number and a name acronym in the case report form. not applicable. the authors declare that they have no competing interests. key: cord-004404-s6udpwxq authors: seifi, najmeh; safarian, mohammad; nematy, mohsen; rezvani, reza; khadem-rezaian, majid; sedaghat, alireza title: effects of synbiotic supplementation on energy and macronutrients homeostasis and muscle wasting of critical care patients: study protocol and a review of previous studies date: 2020-02-24 journal: trials doi: 10.1186/s13063-020-4136-3 sha: doc_id: 4404 cord_uid: s6udpwxq background: an extreme and persistent dysbiosis occurs among critically ill patients, regardless of the heterogeneity of disease. dysbiosis in critically ill patients may make them prone to hospital-acquired infections, sepsis, multi-organ failure (mof), energy homeostasis disturbance, muscle wasting, and cachexia. modulation of gut microbiota through synbiotics can be considered as a potential treatment for muscle wasting and macronutrient homeostasis disturbances. methods: this is a prospective, single-center, double-blind, parallel randomized controlled trial with the aim to evaluate the effects of synbiotic supplementation on energy and macronutrient homeostasis and muscle wasting in critically ill patients. a total of 40 hemodynamically stable, adult, critically ill patients who receive enteral nutrition via a nasogasteric tube (ngt) in the 24–48 h after admission to critical care will be included in this study. eligible patients will be randomly assigned to receive lactocare (zisttakhmir) capsules 500 mg every 12 h or a placebo capsule, which contains only the sterile maize starch and is similar to synbiotic capsules for 14 days. the synbiotic and placebo capsules will be given through the nasogastric tube, separately from gavage, after feeding. discussion: gut microbiota modulation through synbiotics is proposed to improve clinical prognosis and reduce infectious complications, ventilator dependency, and length of icu stay by improving energy and macronutrient homeostasis and reducing muscle protein catabolism. trial registration: iranian registry of clinical trials, irct20190227042857n1. registered on 17 march 2019. the gut microbiota refers to the commensal microorganisms that reside in our gastrointestinal tract (git) with a symbiotic relationship [1] . gut microbiota has a significant role in host metabolism and homeostasis [2, 3] . a disturbance in this microbial community, which leads to an unhealthy state, is called dysbiosis [4] . over the past decade, emerging evidence has demonstrated the role of intestinal dysbiosis in the pathogenesis of various conditions, such as infectious, immune, and metabolic diseases [5] , while it has not been studied extensively in critical illness. an extreme and persistent dysbiosis occurs among critically ill patients, regardless of the heterogeneity of disease. the extreme dysbiosis in patients under critical care is due to the stress of critical illness, multiple antibiotics and additional pharmacological interventions, and highly processed enteral/parenteral nutrition [6, 7] . dysbiosis in critically ill patients may make them prone to hospital-acquired infections, sepsis, multi-organ failure (mof), energy homeostasis disturbance, muscle wasting, and cachexia [6, 8, 9] . the majority of patients in the intensive care unit (icu) have had a severe illness, trauma, or major surgery, and accordingly they are unable to manage their nutritional demands. although nutritional support is a daily practice in the icu, many patients still suffer from malnutrition due to lack of intake or uptake of nutrients [10] . the prevalence of malnutrition in the icu within developed and developing countries is reported as 50.8% and 78.1%, respectively [11] . malnutrition is independently associated with longer icu stay, more icu readmissions, and a higher incidence of infections and risk of mortality [11] . a greater degree of malnutrition is also associated with a higher risk of 28-day mortality [12] . malnutrition further tends toward acute or chronic loss of muscle bulk and function [13] . the gut microbiota and their derived metabolites play an essential role in the absorption, storage, and consumption of energy derived from the diet [14, 15] . previous studies suggest that modulating gut microbiota by novel therapeutics, such as prebiotics, probiotics, or synbiotics, can have an effect on gastrointestinal tolerance and complications of enteral nutrition, which eventually lead to the regulation of energy intake. recently, tuncay et al. showed that enteric formula with prebiotic content in patients under neurocritical care was associated with a significant increase in total feed volume and energy intake and a non-significant tendency to achieve a target dose of nutrition more frequently and earlier [16] . malik et al. also found that in patients in the icu, receiving enteral formula supplemented with probiotics led to a faster return of gut function (tolerated feeding of 80% of their estimated required calories for 48 h consecutively) [17] . however, sanaie et al. demonstrated that daily energy and protein intake in patients receiving probiotic supplements on the icu were not significantly different from the group receiving placebo [18] . in the critical care setting, diarrhea is the most obvious complication of enteral nutrition (en), which is associated with the inadequacy of energy and macronutrient intake [16] . previous systematic reviews have confirmed the significant benefit of probiotics in the reduction of diarrhea in hospital patients overall. but a recent meta-analysis focused on patients in the icu found no benefit of probiotics in preventing or treating diarrhea [19] . besides, in the dysbiosis state of critical illness, microbial products that reach distant organs like brain, adipose tissue, and liver, favor the development of immune-mediated diseases and metabolic alterations [20] . gut microbiota metabolites like short-chain fatty acids (scfas) can also influence the immune system and host metabolism, which regulates energy homeostasis [20] . thus, gut microbiota modulation may be beneficial in the regulation of immune and metabolic responses and energy homeostasis. muscle wasting, characterized by loss of muscle mass and strength, is associated with negative health outcomes such as functional disability, greater risk of infections, delayed recovery, poor life quality, and mortality [21] . the gut microbiota have been reported to influence muscle metabolism. the molecular mechanisms of this gut-muscle axis remain to be identified. gut microbiota influence amino acid bioavailability and are sources of different metabolites, such as conjugated linoleic acid, acetate, and bile acids, which modulate muscle metabolism [8] . various pathogen-associated molecular patterns (pamps) activate the transcription factor nuclear factor kappa light chain enhancer of activated b cells (nf-kb) through toll-like receptors (tlrs) and modulate the production of proinflammatory cytokines, which can induce muscle atrophy [8] (fig. 1) . modulation of gut microbiota through prebiotics, probiotics, or synbiotics can be considered as a potential treatment for muscle wasting and cachexia. in mouse models of leukemia, restoring lactobacillus species by oral supplementation with lactobacillus reuteri 100-23 and lactobacillus gasseri 311,476 reduces inflammatory cytokines and expression of muscle atrophy makers [22] . in another study, bindels et al. showed that prebiotic supplementation in leukemic mice could contribute to delaying anorexia and fat mass sparing by inducing a metabolic shift in adipose tissue [23] . in the mouse models of cancer cachexia, administration of a synbiotic supplement including inulin-type fructans and live l. reuteri 100-23 was associated with restoration of the gut barrier and immune function, thus reducing cachexia. it also prolonged survival [24] . varian et al. also showed that probiotic administration in leukemic mice could inhibit cachexia by reducing systemic inflammation [25] . considering the extreme dysbiosis in critically ill patients and related energy and macronutrients homeostasis disturbance and muscle wasting, prompted us to evaluate the effect of synbiotic supplementation on the elimination of this condition. to our knowledge, this is the first study to investiage the effect of synbiotic supplementation on muscle wasting in critically ill patients. the primary objective is to evaluate the effects of synbiotic supplementation on energy and macronutrient homeostasis and muscle wasting in patients under critical care. the secondary objective is to evaluate the effects of synbiotic supplementation on infectious complications and length of hospital and icu stay in patients under critical care. this is a prospective, single-center, double-blind, parallel randomized controlled trial that will be conducted in edalatian medical icu, emam reza hospital, mashhad, iran. the study protocol was written following the standard protocol items: recommendation for interventional trials (spirit) checklist (additional file 1). participants must meet all the inclusion criteria to participate in this study: adults aged 18-65 years; admitted to the icu; hemodynamically stable within 24-48 h after admission; requiring exclusive enteral nutrition (en) via a nasogastric tube (ngt); not taking any kind of microbial cell preparations (prebiotics probiotics, synbiotics); estimated length of icu stay more than 14 days; and provision of written consent. all candidates meeting any of the exclusion criteria at baseline will be excluded from study participation: pregnancy or lactation; any contraindication to en; any contraindication to insertion of the ngt; receiving immunosuppressive treatment, radiotherapy, or chemotherapy; hematologic disease; acquired immune deficiency syndrome (aids); transplant recipient; known allergy to microbial cell preparations; cancer or autoimmune diseases; artificial heart valve or congenital heart valve disease; estimated length of icu stay less than 4 days; gastric disease; or gastrointestinal tract (gi) tract surgery. before the screening procedure, informed consent will be obtained from every participant who meets the inclusion criteria. first, we will describe the purpose of the study, the procedures involved, the length of time the subject is suspected to participate, any possible disadvantages or discomforts, the benefits of the study to society and individuals, and the person to contact for answers to further questions. we will also emphasize that participation is voluntary, and refusal or withdrawal will not cause any loss of benefits that they are entitled to receive. then the participants or their legal guardian will read and sign two copies of the written form. if, the informed consent was obtained from the patient's guardian because of the patient's lack of competence to consent and then later in the study the patient subsequently became competent as required, consent will be regained. after providing their written consent, patients are randomly allocated in a 1:1 ratio to the intervention or control group (a or b). patients will be randomized through a stratified sequential randomization plan generated online. randomization will be stratified by disease severity (acute physiology and chronic health evaluation (apache) ii, 1 0-35 and 35-70). for allocation concealment, we will use sealed opaque envelopes; inside each there is a carbon paper and the a or b card. to avoid probable selection bias, we will write the patient's name on the envelope before opening it. all patients, researchers, and medical staff will be blinded to the allocation to either synbiotic or placebo capsules. an available third party, the secretary of the icu, will be aware of whether a or b is allocated the synbiotic supplement. in the case of any complication associated with the intervention allocated, the medical staff will refer to the secretary for details. interventions, administration, and duration all eligible patients will receive standard hospital gavage as en through the ngt in the 24-48 h after admission to the icu. according to the recent european society of parenteral and enteral nutrition (espen) guideline on clinical nutrition in the icu [26] , continuous rather than bolus en is preferred because it causes less diarrhea, but there is no difference in other outcomes. another systematic review showed that bolus feeding is associated with lower aspiration rate and better calorie attainment [27] . it also provides a greater stimulus for protein synthesis [28] . considering these data and the availability of bolus en in our hospitals we applied this method. in the absence of an indirect calorimeter, the simple weight-based equation of 20-25 kcal/kg/day in the acute flow phase and 25-30 kcal/kg/day in the anabolic flow phase is preferred for measurement of calorie requirements. for overweight and obese patients, ideal body weight: 0.9 × height (cm) − 100 (male) (or − 106 (female) is suggested as a reference weight [26] . to avoid overfeeding, the en target will be prescribed within 3 days in patients with high nutritional risk and within 7 days in patients with low nutritional risk according to the modified nutrition risk in critically ill (nutric) 2 score. the flow charts in figs. 2 and 3 will be used for initiation and continuation of en. in the intervention group, patients will receive lactocare (zisttakhmir) capsules 500 mg every 12 h for 14 days. each capsule contains lactobacillus casei 1.5 × 10 9 colony-forming units (cfu), lactobacillus acidophilus 1.5 × 10 10 cfu, lactobacillus rhamnosus 3.5 × 10 9 cfu, lactobacillus bulgaricus 2.5 × 10 8 cfu, bifidobacterium breve 1 × 10 10 cfu, bifidobacterium longum 5 × 10 8 cfu, streptococcus thermophilus 1.5 × 10 8 cfu, and fructooligosaccharides (fos). the probiotics capsule will be given through the ngt, separately from gavage, after feeding. patients in the control group will receive a placebo capsule, which contains only sterile maize starch and is similar to probiotic capsules. the liquid preparations ready for gavage through the ngt are also similar in color and odor. the pharmaceutical company will provide synbiotic and placebo capsules in distinct boxes identified as a or b. synbiotic capsules can be stored at room temperature for 2-3 weeks but the best condition for keeping this product is in the refrigerator at 2-8°c. unused study products will be returned to the company supplying them. concomitant interventions will be: -it is common that patients under critical care receive at least one antibiotic during their icu stay. 1 acute physiology and chronic health evaluation ii 2 nutrition risk in critically ill on the other hand, it is believed that antibiotics have bacteriostatic or bactericidal effects on both pathogenic and non-pathogenic bacteria. so, it is recommended that probiotic and antibiotic administration be separated by at least 2 h hours [29] . -considering their analgesic and sedative properties, opioids are widely used in patients under critical care. opioids are believed to suppress the immune system and delay gi peristalsis [30] . delayed peristalsis can increase bacterial translocation out of the gi tract [31] . -prevention of gi tract (git) stress ulcers, through h2 receptor blockers or proton-pump inhibitors, is common in critical care practice. increase in gi -it is believed that the elevated level of catecholamines in patients under critical care, as prescribed exogenously beside endogenous production, can impair the immune system [33] . these drugs are routinely administered in critical care practice, so we will record and consider them as conflicting factors. as the researcher will administer the capsules to the patients through the ngt, adherence assessment is not required. the schedule of evaluations is shown in table 1 . as shown in fig. 2 , calorie achievement goals are set according to the patients' modified nutric score. in everyday visits, we will evaluate gi signs and symptoms (e.g. vomiting, diarrhea, abdominal distention) and gastric residual volume (grv). if there is no sign or symptom of intolerance and grv is less than 250 ml, en will be increased by 10%. otherwise, we will approach as fig. 3 . energy homeostasis (calorie intakeestimated calorie requirement) will be recorded each day. mid-arm circumference, which is an available anthropometric measurement tool, will be evaluated twice a week. as all patients receiving en should be monitored for some clinical and laboratory variables, we set our monitoring approach as reported by berger mm, et al. [34] , monitoring nutrition in the icu, clinical nutrition (2018). concomitant medications, pressure ulcers, infectious complications, and other adverse events will be recorded every day. the apache ii and sequential organ failure assessment (sofa) will be scored on days 0, 8, and 15. before and after the intervention, fasting blood and 24-h urine samples will be obtained. urine urea nitrogen, 3-methyl histidine, and creatinine will be measured in urine samples. fasting blood glucose, insulin, c-reactive protein (crp) and endotoxins will be measured in fasting blood samples. despite the ample evidence supporting the safety of probiotics in critically ill patients, there are case reports of risks and suggested theoretical risks related to probiotic administration. the most important is the risk of bacteremia and fungemia in high-risk populations, which may be associated with improper use and unintended contamination of central-line catheters [33] . to avoid risk of bacteremia we will not include a high-risk population, such as patients who have recently had major surgery, or patients with short bowel syndrome, fig. 3 . abbreviations: alt alanine aminotransferase, ast aspartate aminotransferase, apache ii acute physiology and chronic health evaluation ii, cl chloride, cr creatinine, gcs glasgow coma scale, grv gastric residual volume, k potassium, mg magnesium, na sodium, nutric nutrition risk in critically ill, p phosphorus, prealb pre-albumin, sofa sequential organ failure assessment, tg triglyceride heart valve disease, artificial heart valve, or patients who are immunocompromised. we will also pay careful attention to the proper administration and handwashing protocols. gene transfer and over-stimulation of the immune system are other suggested theoretical risks, on which there is not yet any evidence in humans [33] . if intervention-related side effects exceed the level reported by previous studies, we will stop the intervention and present the results to the ethics committee of mashhad university of medical sciences (mums) for further decision making. if adverse events are caused by the study intervention, the researcher and medical team will provide timely and proper treatment to participants. data will be analyzed using the intention-to-treat approach. we did not find any similar study that has evaluated our primary objectives. so, we considered one of the main secondary objectives to estimate the required sample size. mahmoodpoor and co-workers [35] reported the icu stay in two study groups as 18.6 ± 8 and 11.6 ± 6.3 days. considering alpha error of 0.05 and power of 80%, the required sample size allowing for 10% dropout is 20 patients in each group. the primary outcomes are 1. energy homeostasis (calorie intake-estimated calorie requirement) 2. protein catabolism (nitrogen balance) -nitrogen balance is a measure of the net change in total body protein. it is the difference between nitrogen eliminated from the body and nitrogen ingested in the diet. a positive or neutral nitrogen balance shows that protein stores are increased or maintained, while a negative nitrogen balance indicates protein mass is decreasing. the practical method for estimating nitrogen balance supposes that total nitrogen loss is equal to urinary urea nitrogen excretion plus 4 g/day additional loss from non-urinary urea nitrogen, gastrointestinal, and insensible losses [36, 37] . to measure the nitrogen balance, during the 24-h urine collection, the total intake of protein will be recorded to calculate nitrogen intake: 24-h urine samples will be immediately delivered to the laboratory to measure urea nitrogen. -3mh is exclusively found in muscle proteins, and after protein degradation, it is rapidly excreted in the urine without further reutilization or metabolization. so, measuring urinary 3mh, after at least 1 day of a meat-free diet, can be used as a biomarker of muscle protein breakdown [38, 39] . after a 1-day meat-free diet, 24-h urine will be collected. urine samples will be centrifuged for 20 min at 1000×g. the supernatant will be collected and stored at − 70°c for a maximum of 2 months. the elisa method will be used for 3mh detection. -since 24-h urinary creatinine estimates the total pool of muscle proteins, muscle protein turnover can be calculated from the 3mh/creatinine excretion ratio [38] . a 24-h urine sample will be delivered to the laboratory to immediately measure creatinine by the enzymatic method. -free glycerol is an important index of lipid metabolism. when the body uses stored fat as the energy supply, glycerol and fatty acids are released into the circulation. the absence of glycerol kinase in the adipocyte decreases triacylglycerol resynthesize and supports hepatic gluconeogenesis [40] . after obtaining the overnight fasting blood sample, the serum will be separated. the serum sample will be stored at − 70°c for further measurement of free glycerol by enzymatic colorimetric method. 6. glucose homeostasis (fasting blood sugar (fbs), insulin) 7. inflammatory status (crp, neutrophil/lymphocyte ratio (nlr)) -nlr is an available measurable marker used to measure systemic inflammation. -intestinal gram-negative bacteria are the major source of lipopolysaccharides (lps), which are referred to as endotoxins. in the case of reduced intestinal barrier integrity due to dysbiosis, luminal endotoxins can enter the circulation [41] . endotoxin activity assay (eaa) will be used to determine endotoxin levels in whole blood. the secondary outcomes are: 1. enteral feeding tolerance (abdominal examination and grv measurement) 2. clinical prognosis (apache and sofa score) 3. nutritional status (nutric score) 4. infectious complications incidence 5. pressure ulcer incidence and grade 6. ventilator-dependent days 7. length of icu stay 8. length of hospital stay 9. 28-day mortality data will be analyzed using spss for windows version 11.5 and medcalc statistical software version 18.11.3 (medcalc software bvba, ostend, belgium; https://www. medcalc.org; 2019). descriptive (frequency, percentage, mean, standard deviation) and inferential analysis (student t test, paired sample t test, repeated measures analysis of variance (anova)) will be performed. any covariates will be controlled by ancova or binary logistic regression. all tests will be two-tailed and a p value <0.05 will be considered as statistically significant. data collection will be supervised by the primary investigator. in addition, 10% of electronic data will be checked randomly with paper questionnaires and any discrepancies will lead to a 50% double-checking of electronic data. any outliers will be checked against patient medical records. in the intestinal tract, gut microbiota control different immune and endocrine functions [42] . they have a major role in the absorption, storage, and consumption of energy derived from the diet [14, 15] . outside the intestine, they also modulate cell metabolism, energy homeostasis, systemic inflammation, appetite and food intake [42, 43] . on the other hand, a few clinical studies, modulating gut microbiota in patients under critical care demonstrated a faster return of gut function and earlier achievement of the nutritional target dose [16, 17] . therefore, we expect that our patients in the intervention group will have a better enteric feeding tolerance and also more desirable energy homeostasis. animal studies have shown that modulation of gut microbiota by prebiotics, probiotics, or synbiotics can reduce cachexia and muscle mass sparing [22] [23] [24] [25] . the underlying mechanisms remain to be identified. gut microbiota influence amino acid bioavailability and are a source of different metabolites such as conjugated linoleic acid, acetate, and bile acids that modulate muscle metabolism. gut microbiota are also a source of pamps, which activate the transcription factor nf-kb through toll-like receptors (tlrs) and cause muscle wasting. gut microbiota also modulate production of proinflammatory cytokines, which can induce muscle atrophy [8] . we expect that synbiotic intervention in patients under critical care reduces muscle protein degradation and turnover. as malnutrition and muscle wasting in these patients are associated with negative health outcomes, gut microbiota modulation will improve the clinical prognosis and reduce infectious complications, ventilator dependency, and length of icu stay. recruitment was started on 1 march 2019 and is estimated to be completed by october 2019. recruitment was ongoing at the time of submission. this is the last protocol version (number 5, 15 january 2020). additional file 1. standard protocol items: recommendation for interventional trials (spirit) 2013 checklist: recommended items to address in a clinical trial protocol and related documents. the support provided by mashhad university of medical sciences (mums) to conduct this study is highly acknowledged. participants' study information will be stored at the security site. all laboratory specimens, data collected, and reports will be identified by a coded id number. we will attempt to release the full study protocol and results as soon as possible, regardless of the magnitude or direction of effect. the anonymized data set and statistical code may be available from the corresponding author on reasonable request. authors' contributions ns and ms initially conceptualized and designed the study. ms, as, mn, and rr upgraded the protocol design and contributed to obtaining initial funding. the manuscript was written by ns and reviewed by all members. mkr was responsible for design optimizing and statistical analysis. all authors read and approved the final manuscript. this research will be funded by the vice chancellery for research of mashhad university of medical sciences (mums), and all study stages will be undertaken under its supervision. the datasets generated and/or analyzed during the current study are not publicly available due to ethical considerations, but may be available from the corresponding author on reasonable request. ethics approval and consent to participate ethical approval was obtained from ethical committee of mums. the ethical approval code is ir.mums.medical.rec.1397.715. the informed consent will be obtained from all study participants or their legal guardian. any modification to protocol which may impact on the conduct of the study, will be approved by ethical committee of mums prior to implementation. gut microbiota in health and disease current understanding of the human microbiome the role of the microbiome in human health and disease: an introduction for clinicians the impact of probiotics' administration on glycemic control, body composition, gut microbiome, mitochondria, and other hormonal signals in adolescents with prediabetesa randomized, controlled trial study protocol gut microbiota: an integral moderator in health and disease role of the microbiome, probiotics, and 'dysbiosis therapy' in critical illness the re-emerging role of the intestinal microflora in critical illness and inflammation: why the gut hypothesis of sepsis syndrome will not go away muscle wasting: the gut microbiota as a new therapeutic target? gut barrier dysfunction and microbial translocation in cancer cachexia: a new therapeutic target malnutrition in critically ill patients in intensive care units association between malnutrition and clinical outcomes in the intensive care unit: a systematic review association between malnutrition and 28-day mortality and intensive care length-ofstay in the critically ill: a prospective cohort study diagnostic criteria for malnutrition-an espen consensus statement gut microbiota, nutrient sensing and energy balance gut microbiota and energy balance: role in obesity use of standard enteral formula versus enteric formula with prebiotic content in nutrition therapy: a randomized controlled study among neuro-critical care patients microbial cell preparation in enteral feeding in critically ill patients: a randomized, doubleblind, placebo-controlled clinical trial effect of a multispecies probiotic on inflammatory markers in critically ill patients: a randomized, double-blind, placebocontrolled trial probiotic and synbiotic therapy in critical illness: a systematic review and meta-analysis the immune system bridges the gut microbiota with systemic energy homeostasis: focus on tlrs, mucosal barrier, and scfas muscle loss: the new malnutrition challenge in clinical practice restoring specific lactobacilli levels decreases inflammation and muscle atrophy markers in an acute leukemia mouse model non digestible oligosaccharides modulate the gut microbiota to control the development of leukemia and associated cachexia in mice synbiotic approach restores intestinal homeostasis and prolongs survival in leukaemic mice with cachexia beneficial bacteria inhibit cachexia espen guideline on clinical nutrition in the intensive care unit effectiveness of continuous enteral nutrition versus intermittent enteral nutrition in intensive care patients: a systematic review intermittent versus continuous feeding in critically ill adults treatment of opioid-induced gut dysfunction bacterial translocation: overview of mechanisms and clinical impact gastric acid reduction leads to an alteration in lower intestinal microflora probiotics in the critical care unit: fad, fact, or fiction? monitoring nutrition in the icu effect of a probiotic preparation on ventilator-associated pneumonia in critically ill patients admitted to the intensive care unit: a prospective double-blind randomized controlled trial assessment of protein and energy nutritional status. nutritional management of renal disease nitrogen balance and protein requirements for critically ill older patients clinical usefulness of urinary 3-methylhistidine excretion in indicating muscle protein breakdown the influence of dietary habits and meat consumption on plasma 3-methylhistidine-a potential marker for muscle protein turnover lipolysis in adipocytes understanding intestinal lipopolysaccharide permeability and associated inflammation interaction between obesity and the gut microbiota: relevance in nutrition role of gastrointestinal hormones in feeding behavior and obesity treatment publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations no personal identifying information will be published. the authors declare that they have no competing interests. key: cord-004168-rqd9b13s authors: daneman, nick; rishu, asgar h.; pinto, ruxandra; arabi, yaseen; belley-cote, emilie p.; cirone, robert; downing, mark; cook, deborah j.; hall, richard; mcguinness, shay; mcintyre, lauralyn; muscedere, john; parke, rachael; reynolds, steven; rogers, benjamin a.; shehabi, yahya; shin, phillip; whitlock, richard; fowler, robert a. title: a pilot randomized controlled trial of 7 versus 14 days of antibiotic treatment for bloodstream infection on non-intensive care versus intensive care wards date: 2020-01-15 journal: trials doi: 10.1186/s13063-019-4033-9 sha: doc_id: 4168 cord_uid: rqd9b13s background: the optimal treatment duration for patients with bloodstream infection is understudied. the bacteremia antibiotic length actually needed for clinical effectiveness (balance) pilot randomized clinical trial (rct) determined that it was feasible to enroll and randomize intensive care unit (icu) patients with bloodstream infection to 7 versus 14 days of treatment, and served as the vanguard for the ongoing balance main rct. we performed this balance-ward pilot rct to examine the feasibility and impact of potentially extending the balance main rct to include patients hospitalized on non-icu wards. methods: we conducted an open pilot rct among a subset of six sites participating in the ongoing balance rct, randomizing patients with positive non-staphylococcus aureus blood cultures on non-icu wards to 7 versus 14 days of antibiotic treatment. the co-primary feasibility outcomes were recruitment rate and adherence to treatment duration protocol. we compared feasibility outcomes, patient/pathogen characteristics, and overall outcomes among those enrolled in this balance-ward and prior balance-icu pilot rcts. we estimated the sample size and non-inferiority margin impacts of expanding the balance main rct to include non-icu patients. results: a total of 134 patients were recruited over 47 site-months (mean 2.9 patients/site-month, median 1.0, range 0.1–4.4 patients/site-month). the overall recruitment rate exceeded the balance-icu pilot rct (mean 1.10 patients/site-month, p < 0.0001). overall protocol adherence also exceeded the adherence in the balance-icu pilot rct (125/134, 93% vs 89/115, 77%, p = 0.0003). balance-ward patients were older, with lower sequential organ failure assessment scores, and higher proportions of infections caused by escherichia coli and genito-urinary sources of bloodstream infection. the balance-ward pilot rct patients had an overall 90-day mortality rate of 17/133 (12.8%), which was comparable to the 90-day mortality rate in the icu pilot rct (17/115, 14.8%) (p = 0.65). simulation models indicated there would be minimal sample size and non-inferiority margin implications of expanding enrolment to increasing proportions of non-icu versus icu patients. conclusion: it is feasible to enroll non-icu patients in a trial of 7 versus 14 days of antibiotics for bloodstream infection, and expanding the balance rct hospital-wide has the potential to improve the timeliness and generalizability of trial results. trial registration: clinicaltrials.gov, nct02917551. registered on september 28, 2016. (continued from previous page) indicated there would be minimal sample size and non-inferiority margin implications of expanding enrolment to increasing proportions of non-icu versus icu patients. conclusion: it is feasible to enroll non-icu patients in a trial of 7 versus 14 days of antibiotics for bloodstream infection, and expanding the balance rct hospital-wide has the potential to improve the timeliness and generalizability of trial results. trial registration: clinicaltrials.gov, nct02917551. registered on september 28, 2016. keywords: bacteremia, bloodstream infection, critical care, intensive care, duration of treatment the world health organization has declared antibiotic resistance a global public health threat, based on rising rates of resistant pathogens and diminishing rates of new antibiotic development [1] . antimicrobial stewardship is a cornerstone of efforts to counter this threat. however, evidence-informed stewardship treatment decisions for patients with life-threatening illnesses such as bloodstream infections are challenging because little evidence exists for the optimal duration of treatment. among patients with suspected bloodstream infections, broad-spectrum antibiotics must be initiated empirically because early adequate empiric treatment is associated with improved survival [2, 3] . due to the rising prevalence of resistant organisms, the tailoring or deescalation of these empiric regimens is not possible even when blood culture and susceptibility results become available. patients must then remain on broad-spectrum agents for their full treatment course [4] . therefore, shortening total treatment durations may be the most feasible approach to minimize patient-level and societallevel antimicrobial harms [5] . our systematic review, national practice survey, and observational studies have documented a lack of evidence to guide optimal treatment durations for bloodstream infections, wide variation in clinical practice, and collective equipoise for a trial of 7 versus 14 days of antibiotic treatment for patients with bloodstream infections [6] [7] [8] . through the bacteremia antibiotic length actually needed for clinical effectiveness (balance) pilot randomized controlled trial (clinicaltrials.gov nct02261506) we documented the feasibility of this trial design among 115 patients in intensive care units (icus) [9] . these patients served as a vanguard for the balance main trial (clini-caltrials.gov nct03005145), which has recruited more than 600 patients across a growing number of icu sites and countries. the canadian critical care trials group (ccctg) and australian & new zealand intensive care society clinical trials group (anzics ctg) began the bal-ance trial in the icu setting. as the majority of patients with bacteremia are cared for on general medical and surgical wards, we began to explore hospital-wide expansion to the full population of hospitalized patients with bacteremia as a means to improve the generalizability and timeliness of the balance rct. we first conducted a distinct balance pilot trial focused on patients admitted to general hospital wards at the balance central study site. we then expanded this approach to several community and academic hospitals participating in the balance trial (clinicaltrials.gov nct02917551). the objectives of this multi-centre balance-ward pilot rct were three-fold: (1) to test the feasibility of ward (non-icu) recruitment into this trial; (2) to compare the patient, pathogen, and outcome characteristics among patients enrolled in the balance-ward pilot rct to characteristics in the prior balance-icu pilot rct; and (3) to estimate the sample size and noninferiority margin impacts of merging the balance-ward pilot with the balance main trial. we conducted a pilot rct of 7 versus 14 days of antibiotic treatment for patients with bloodstream infection, which was identical to our prior balance-icu pilot rct [9, 10] , except that it focused on patients admitted to general medical and surgical wards. in this balance-ward pilot trial, as per the prior balance-icu pilot trial focused on critically ill patients, randomization was determined through a central, web-based system (http://www. randomize.net) with variable block sizes of four to six patients, stratified by site. the intervention related only to the duration of treatment, with patients randomized 1:1 in parallel to 7 versus 14 days of treatment. all other aspects of care (antibiotic selection, doses, intervals, routes of delivery, and timing of hospital discharge) were at the discretion of the clinical team. participant and clinician blinding and placebo controls were not used given the diversity of pathogens and underlying foci of infection, but allocation concealment was maintained until the seventh day of treatment to mitigate selection bias and differential treatment. the central study team and statistician were blinded to treatment group. the balance-ward pilot trial was registered separately on clinicaltrials.gov (nct02917551), with unique ethics approval at all participating sites, so that enrolled patients could be kept distinct from the main trial until completion of the pilot and evaluation of feasibility. the balance-ward pilot trial was launched at sunnybrook health sciences centre (shsc) in october 2016, and then after 1 year extended to five other active bal-ance sites, including the ottawa hospital (toh), kingston general hospital (kgh), hamilton general hospital (hgh), st. joseph's health centre (sjhc) toronto, and north york general hospital (nygh). the inclusion criteria differed, by definition, from the prior balance pilot rct [9, 10] in that we considered all adult patients with a blood culture reported as positive with a pathogenic bacterium while on a non-icu ward rather than reported as positive while in an icu. however, the exclusion criteria were unchanged from the balance pilot rct: previously enrolled patients, those with neutropenia, organ transplantation, prosthetic valves, endovascular grafts, suspected or documented syndromes requiring prolonged treatment (endocarditis, osteomyelitis, undrained abscess, unremoved prosthetic infection), patients with a single positive culture of a common contaminant organism, or bloodstream infection with staphylococcus aureus, staphylococcus lugdunensis, or fungal organisms. potentially eligible patients were identified through microbiology laboratory reports of positive blood cultures. the site research coordinator screened the medical records of these patients to confirm that they met all inclusion criteria, and no exclusion criteria, and then provided patients with study information materials. consenting patients could be enrolled any time up to the seventh day of adequate antibiotic treatment [10] . as per the original balance-icu pilot rct, the coprimary feasibility outcomes were (1) recruitment rates and (2) adherence to treatment protocol. protocol adherence was defined as receipt of 7 ± 2 days of antibiotics or 14 ± 2 days of antibiotics for patients randomized to shorter versus longer duration treatment, respectively. we did not target a specific protocol adherence rate to consider the trial feasible, but sought to determine whether the protocol adherence rate would exceed the rate seen in the balance icu pilot rct (77%) [9] . as with the balance icu pilot rct, we expected that there would be some patients for whom clinicians would continue antibiotic treatment beyond the assigned duration because of concerns of new infection, persistent infection, or previously unrecognized deep-seated infection. these were counted as protocol deviations. the target recruitment rate was an average of one patient per site per month to consider including ward enrolments in the bal-ance main trial. the panel of secondary clinical outcomes (e.g., length of stay, mortality, antibiotic-free days, clostridiodes difficile, and antibiotic resistant organisms) were identical to those collected in the original balance pilot rct [9, 10] . included among these secondary outcomes was the planned primary outcome from the main balance rct, 90-day mortality. antibiotic-free days were calculated as the number of days alive and not on any antibiotics in the time period from collection of the index blood culture to 28 days after this date; patients that died prior to day 28 were assigned 0 antibiotic-free days. treatment adherence and clinical outcomes were recorded by the site research coordinator, via chart review and discussion with the clinical team if needed. patients were followed throughout the hospital stay to a 90-day maximum, with capture of baseline characteristics and outcome information on the same electronic case report form used for the balance main trial. ninety-day mortality was collected via follow-up phone call 90 days from the index bacteremia. there were no interim analyses or stopping rules within this pilot rct. as with our initial balance pilot rct, we planned a priori to maintain blinding of treatment assignment in the balance-ward pilot rct [11] . a feasibility pilot rct is not powered to identify clinically important differences in safety or efficacy endpoints, but rather this is the goal of the balance main rct. we analyzed the balance-ward pilot rct results as a single cohort, describing overall rates of recruitment per site per month and overall protocol adherence as the coprimary feasibility outcomes of interest. next, we compared these feasibility outcomes to those achieved during our initial balance-icu pilot rct [9] . poisson regression was used to compare recruitment rates per month in the icu versus non-icu pilots; chisquare test was used to compare protocol adherence. to further evaluate the difference between the two pilot rcts we compared baseline patient characteristics, pathogens, foci of infection, and clinical outcomes among ward and icu patients; the chi-square test or fischer's exact test were used to compare categorical variables, while a t-test or the wilcoxon rank sum test were used to compare continuous variables. the wilson score method was used to determine 95% confidence intervals. p values were not adjusted for multiple comparisons. if the balance-ward pilot demonstrated feasibility, we planned to consider merging the ward-based protocol with the icu-based protocol of the balance main trial. therefore, we estimated the percentage of recruited patients that would be enrolled from icu versus non-icu wards as a function of the percentage of sites expanding to hospital-wide enrolments. next, we estimated the impact on overall trial sample size and noninferiority margins as a function of the proportion of anticipated icu versus ward enrolments at the time of trial completion. for these calculations we estimated the 90day mortality for ward patients using outcome data from this ward pilot rct, and we estimated the mortality for icu patients from up-to-date data from the ongoing balance main rct. at the time the ward pilot was completed, 600 patients had been enrolled and reached the 90-day endpoint in the balance main trial. we sought to enroll a minimum of 115 patients (to equal the sample size of our balance-icu pilot) [9] , but to improve generalizability of the balance-ward pilot trial we planned to continue enrolment until successful enrolment of at least one patient at all five additional non-central study sites. recruitment extended from 17 october 2016 to 12 december 2018. a total of 1573 non-icu patients diagnosed with bacteremia on hospital wards were screened for study eligibility, of whom 605 (38%) were deemed eligible for enrolment (fig. 1) . the most common reasons for noneligibility among the 968 excluded patients were single positive cultures with contaminant organisms (458), syndromes with well-defined requirement for prolonged treatment (195), and s. aureus bacteremia (177). of eligible patients, 134/605 (22%) were enrolled and randomized (fig. 1) ; this percentage ranged from 3 to 57% across participating sites (table 1) . a total of 134 patients were recruited over 47 sitemonths (mean 2.9 patients/site-month; table 1 ). the recruitment rate varied across the six participating sites: hospital a (4.1 patients per month, over 26.9 months), hospital b (4.4 patients/month, over 3.6 months), hospital c (1.1 patient/month, over 3.7 months), hospital d (0.1 patients per month, over 6.7 months), hospital e (1.0 patients/month, over 1 month), and hospital f (0.4 patients/month, over 5.1 months) ( table 1 ). the overall recruitment rate significantly exceeded the recruitment rate in the balance-icu pilot rct (2.9 patients/sitemonth vs 1.1 patients/site-month, p < 0.0001). the overall adherence to treatment duration protocol was 125/134 (93%), with minimal variation across study sites: shsc 103/110, sjhc 15/16, toh 1/1, kgh 1/2, nygh 4/4, hgh 1/1 (table 1) . overall protocol adherence significantly exceeded the adherence achieved in the balance-icu pilot rct (125/134, 93% vs 89/115, 77%, p = 0.0003). patients enrolled in the balance-ward pilot rct were older than those enrolled in the icu pilot rct (median (iqr) 72(62-82) vs 67(57-78) years, p = 0.010), but had a lower sequential organ failure assessment (sofa) score (2(0-3) vs 6 (4-9), p < 0.0001) on the day blood cultures were collected ( table 2) . a greater proportion of the bacteremias in non-icu ward patients were community-acquired (84 vs 60%, p < 0.0001), and a greater proportion were due to genito-urinary sources of infection (49 vs 23%, p < 0.0001) and/or e. coli as a causative pathogen (49 vs 24%, p < 0.0001) ( table 2) . however, a broad variety of pathogens was still implicated in the non-icu infections (30 pathogens among the 134 patients), and the top ten pathogen list was similar to the top pathogens seen in the balance-icu pilot rct (table 2) . as per a priori plans, we did not examine clinical outcomes separated by treatment duration arm in this pilot rct. the balance-ward pilot rct patients had an overall 90-day mortality rate of 17/133 (12.8%, 95% ci 8.1-19.5%), which was similar to the 90-day mortality rate in the icu pilot rct (17/115, 14.8%, 95% ci 9.4-22.4%) (p = 0.65; table 3 ) and mortality estimates from the main balance rct as of 600 patients enrolled (104/600, 17.3%, 95% ci 14.5-20.6%). the patients in the balance-ward pilot had a shorter median (iqr) length of hospital stay (6 (4-12) vs 20(12-43) days, p < 0.001) and more antibiotic-free days by day 28 (14(14-21) vs 14(8-17), p < 0.0001) ( table 3 ). only one patient was lost to follow-up at 90 days, but there are ongoing efforts to ascertain final vital status for this patient. assuming average enrolment rates in the icu based on up-to-date data from the balance main trial, as well as ward enrolment rates from this balance-ward pilot rct, we are able to estimate how the final proportion of icu versus non-icu patients will vary according all data are presented as n (%) or medians (interquartile ranges) unless otherwise specified a one patient in the ward-pilot group and one patient in the icu-pilot group have unknown comorbidities b a total of 32 different bacterial species were isolated among the index blood cultures of the 115 icu patients; a total of 30 different species were isolated among the 134 ward patients sofa sequential organ failure assessment to the proportion of sites that choose to expand enrolment onto non-icu wards (fig. 2) . even under scenarios in which three-quarters of sites expand to non-icu wards, the final study population will still be comprised of nearly half icu patients (fig. 2) . assuming a 90-day mortality rate of 12.8% among bal-ance ward patients and 17.3% among balance-icu patients (based on most up-to-date data from the main balance trial), merging ward patients into the main trial would result in an overall mortality rate of 15% if there were equal numbers of ward and icu patients. figures 3 and 4 depict the sample size and noninferiority margin implications of merging ward patients into the balance rct as a function of the final percentage of ward patients enrolled. in the prior balance-icu pilot rct we demonstrated that it was feasible to enroll icu patients into a trial of 7 versus 14 days of treatment for bloodstream infection [9] , thereby providing the vanguard patients for the multinational, multicentre balance main rct. in this subsequent balance-ward pilot rct, we have confirmed that it is feasible to enroll patients cared for on general hospital wards and have clarified the viability and implications of expanding the balance main rct to include hospital-wide patients with bacteremia. the balance-ward pilot rct documented feasibility with respect to both co-primary outcomes of recruitment rate and protocol adherence. we achieved mean recruitment rates of 2.9 patients per site-month; the median recruitment rate per site per month was lower (1.0) but still met our feasibility target. similarly, we achieved protocol adherence rates of 93%, which exceeded the 77% adherence rates in the icu population. on the basis of these co-primary outcomes it appears feasible that the balance rct could be extended from icus to include non-icu patients. the increased recruitment rate on the wards can be attributed to the larger number of bacteremic patients than those who are in the icu. the superior protocol adherence rates on the general wards may be due to the lower severity of illness and lower risk of secondary nosocomial infections among these patients with shorter lengths of hospital stay and fewer indwelling devices such as endotracheal tubes and central venous catheters. as expected, there were some measurable differences in critically ill patients with bacteremia enrolled in the initial balance pilot compared to the patients on the wards who were enrolled in this pilot. the latter were older, had lower severity of illness at baseline, and more commonly had community-acquired bacteremia, genitourinary sources of infection, and e. coli as a causative pathogen. on the one hand, merging non-icu patients with icu patients into a single trial could be viewed as mixing two heterogeneous populations together. on the other hand, combining these patients together could be considered as reflecting a broader population of patients all data are presented as medians and interquartile ranges unless otherwise specified a based on up-to-date data from the first 600 icu patients enrolled in the balance main rct b one patient loss to follow-up for 90-day outcome (but ongoing efforts underway to ascertain vital status) with bloodstream infection, yielding more generalizable trial results. the icu and non-icu pilot trial patients were both infected with a diverse range of gram negative and gram positive bacterial pathogens, and each included patients with a diverse range of host comorbidities. typically a trial based on a specific diagnosis (e.g., pulmonary embolism, myocardial infarction) would be conducted across the full spectrum of severity, including those patients admitted to icu and non-icu wards. conceptually, enrolling both non-icu and icu patients captures the full spectrum of bacteremic illness, and the patients are only dichotomized by the location of care within the hospital. the 90-day mortality rate in this pilot rct (12.8%) was similar to the mortality rate seen in a recently published rct of 604 patients allocated to 7 versus 14 days of antibiotics for patients with gram negative bacteremia conducted on non-icu wards in three centers in israel and italy [12] . as expected, the 90-day mortality rate was lower than that seen in our prior balance-icu pilot rct (15%) [9] . the mortality difference between non-icu and icu patients is even wider than the icu pilot data suggest, because a more updated mortality estimate from the balance main trial suggests that the mortality has risen to 17.3%. at a fixed non-inferiority margin of 4%, adding non-icu ward patients in the study would decrease our total sample size requirement (fig. 3) ; maintaining our sample size target would enable us to reduce the achievable absolute non-inferiority margin (fig. 4) . it is important to note that our 4% non-inferiority margin is already much smaller than the noninferiority margins used in recent trials of antibiotic treatment duration in patients with serious bacterial infections [12] [13] [14] [15] , and is also much lower than the us federal drug administration recommendation of noninferiority margins for ventilator-associated pneumonia [16] . therefore, we have opted to maintain our current overall sample size target (n = 3626) for the balance main trial. our balance-ward pilot rct enrolled patients in six sites, and so we cannot be certain that the recruitment and adherence results would be generalizable to all of the sites involved in the balance main rct. however, the generalizability is bolstered by inclusion of a mix of both community and academic hospitals, as well as sites with long-standing versus recent involvement in the ccctg. another limitation is that we cannot predict whether expansion to include non-icu enrolment will lead to a compensatory decrease in icu recruitments by diluting study teams' efforts across broader clinical units. in our six pilot rct sites, though, we did not see reductions in icu recruitments. as balance is expanded hospital-wide, we will assess the interplay of icu and non-icu recruitment rates over time. the low rate of enrolment of eligible ward patients, and wide variation across sites, suggests that further efforts may be necessary to foster enrolments, including educating ward clinicians about the pre-rct work which has documented practice heterogeneity and collective clinical equipoise. the balance-ward pilot rct experience suggests that sites with infectious diseases engagement on the study team achieve much higher recruitment rates and percent enrolment of eligible patients, and so this will be crucial for future sites considering hospitalwide recruitment. we will also need to track eligible non-enrolled patients, along with recruitment rates and protocol adherence, as a site-specific metric throughout the conduct of the trial. the balance steering committee and ccctg have guided us in conducting step-wise pilots of the bal-ance rct protocol in the initial icu population, and now in this non-icu population, once again confirming the feasibility of the balance trial design on general hospital wards. we have carefully reviewed the onegroup findings (maintaining allocation concealment) with the ccctg and the balance international steering committee, both of which have strongly endorsed the option for participating balance sites to extend enrolments hospital-wide. given the success of this non-icu pilot, no other protocol changes are required to facilitate inclusion of non-icu patients in the balance main trial. a detailed statistical analysis plan involving the entire cohort will be published before the trial is completed; randomization will be stratified by icu and non-icu ward location, and a subgroup analysis will be conducted. the subgroup analyses, by definition, will not be powered to achieve the same non-inferiority margin as the overall balance trial population. however, the achievable non-inferiority margins within the icu and non-icu subgroups will still be less than the noninferiority margins used in recent landmark antimicrobial minimization studies involving patients with serious bacterial infections [4, [13] [14] [15] . we anticipate that the final balance trial results will be more generalizable to the full population of patients admitted to hospital with bloodstream infections, and yet will include a majority of critically ill patients, ensuring that the data are relevant to our sickest of patients. in doing so, we hope that balance will provide an evidence foundation for the treatment of a broad range of patients with non-s. aureus bacteremia, and allow us to maximize the benefits while minimizing the harms of antimicrobial treatments for bloodstream infections. departments of critical care medicine and anesthesiology, pain management and perioperative medicine systematic review and meta-analysis of the efficacy of appropriate empiric antibiotic therapy for sepsis duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock effect of piperacillin-tazobactam vs meropenem on 30-day mortality for patients with e. coli or klebsiella pneumoniae bloodstream infection and ceftriaxone resistance: a randomized clinical trial shortening antibiotic treatment durations for bacteremia duration of antibiotic therapy for bacteremia: a systematic review and meta-analysis antibiotic treatment duration for bloodstream infections in critically ill patients: a national survey of canadian infectious diseases and critical care specialists duration of antimicrobial treatment for bacteremia in canadian critically ill patients 7 versus 14 days of antibiotic treatment for critically ill patients with bloodstream infection: a pilot randomized clinical trial bacteremia antibiotic length actually needed for clinical effectiveness (balance): study protocol for a pilot randomized controlled trial the design and interpretation of pilot trials in clinical research in critical care seven versus fourteen days of antibiotic therapy for uncomplicated gram-negative bacteremia: a noninferiority randomized controlled trial comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial trial of short-course antimicrobial therapy for intraabdominal infection partial oral versus intravenous antibiotic treatment of endocarditis guidance for industry hospital-acquired bacterial pneumonia and ventilator asssociated bacterial pneumonia: developing drugs for treatment. 5-5-2014. ref type: online source springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to acknowledge the extraordinary efforts of the research coordinators at each participating site in screening and enrolling eligible patients, including kanthi kavikondala, miranda hunt, shelley acres, rebecca porteous, irene watpool, alexandra sabev, nevena savija, katrina fimiani, alexandra lostun, and rizani ravindran. we also like to acknowledge the crucial contributions of lisa buckingham and nicole zytaruk at the clarity methods centre in helping to develop the electronic case report form and database. we thank allan garland and kirsten feist for providing internal manuscript review within the ccctg.authors' contributions nd and raf conceived and designed the study, obtained funding, developed the statistical analysis plan, database development, drafted the manuscript, and are responsible for overall management and supervision. ahr participated in the study design, helped develop paper and electronic crf and web randomization and drafting of the manuscript. rp contributed to the study design, provided statistical and methodological expertise, and helped draft the manuscript. ya, epbc, rc, md, djc, rh, sm, lm, jm, rp, sr, br, ys, ps, and rw participated in the study design, contributed to writing grant applications, and helped in reviewing and revising the manuscript for intellectual content. all the authors have reviewed and approved the manuscript for publication. the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.ethics approval and consent to participate key: cord-012934-c6pbr64i authors: hao, weiming; zhao, liping; yu, huiqian; li, huawei title: vestibular prognosis in idiopathic sudden sensorineural hearing loss with vestibular dysfunction treated with oral or intratympanic glucocorticoids: a protocol for randomized controlled trial date: 2020-07-22 journal: trials doi: 10.1186/s13063-020-04579-6 sha: doc_id: 12934 cord_uid: c6pbr64i background: idiopathic sudden sensorineural hearing loss (issnhl) is a rapid-onset sensorineural hearing impairment with unclear etiology and unsatisfying treatment effects. vestibular dysfunction has been considered as a poor indicator in the clinical manifestations and prognosis of issnhl, which occurred in approximately 28–57% cases. glucocorticoids, administered through oral or intratympanic way, are currently regularly and standardly applied for issnhl to improve the hearing outcome. however, the vestibular prognosis of issnhl after routine treatments remains seldom explored. this study aims to compare the effectiveness of oral and intratympanic glucocorticoids in issnhl with vestibular dysfunction in terms of the pattern and trajectory of possible process of vestibular function recovery. methods/design: a randomized, outcome-assessorand analyst-blinded, controlled, clinical trial (rct) will be carried out. seventy-two patients with issnhl complaining of vestibular dysfunction appearing as vertigo or imbalance will be recruited and randomized into either oral or intratympanic glucocorticoid therapy group with a 1:1 allocation ratio. the primary outcomes will be vestibular function outcomes assessed by sensory organization test, caloric test, video head impulse test, cervical vestibular evoked myogenic potential, and ocular vestibular evoked myogenic potential; the secondary outcomes include self-reported vestibular dysfunction symptoms; dizziness-related handicap, visual analogue scale for vertigo and tinnitus; and pure tone audiometry. assessments of primary outcomes will be performed at baseline and at 4 and 8 weeks post-randomization, while assessments of secondary outcomes will be performed at baseline and 1, 2, 4, and 8 weeks post-randomization. discussion: previous intervention studies of issnhl included only hearing outcomes, with little attention paid on the prognosis of vestibular dysfunction. this trial will be the first rct study focusing on the progress and prognosis of vestibular dysfunction in issnhl. the efficacy of two commonly used therapies of glucocorticoids will be compared in both auditory and vestibular function fields, rather than in the hearing outcome alone. trial registration: clinicaltrials.gov nct03974867. registered on 23 july 2019 discussion: previous intervention studies of issnhl included only hearing outcomes, with little attention paid on the prognosis of vestibular dysfunction. this trial will be the first rct study focusing on the progress and prognosis of vestibular dysfunction in issnhl. the efficacy of two commonly used therapies of glucocorticoids will be compared in both auditory and vestibular function fields, rather than in the hearing outcome alone. trial registration: clinicaltrials.gov nct03974867. registered on 23 july 2019 keywords: randomized controlled trial, vestibular function, sudden hearing loss, glucocorticoid background sudden sensorineural hearing loss (ssnhl) is a rapidonset inner ear disease. it is defined as a sensorineural hearing loss of at least 30 db over at least three test frequencies occurring within 72 h [1, 2] . the reported incidence rate of ssnhl is about 5-27/100,000 people per year [1] , which has been widely considered underestimated because of the unregistered cases with out-ofhospital spontaneous recoveries. the etiology in about 71 to 90% of ssnhl cases remains uncertain, which is defined as idiopathic ssnhl (issnhl) [1, 3] . various postulated etiological theories have been proposed including microvascular impairment, viral infections, inner ear electrolytic disorders, trauma, autoimmune diseases, and central nervous system (cns) diseases [3] [4] [5] [6] [7] . based on the close anatomic relationship between cochlea and vestibule, approximately 28-57% of issnhl patients have also reported of co-occurring symptoms of vertigo [8] . there are two administration patterns of glucocorticoids for issnhl: systemic (oral or intravenous) and intratympanic therapies. compared with the traditional oral administration, intratympanic therapy is thought to be superior for its (1) bypassing the blood-labyrinth barrier and achieving higher drug concentrates in the inner ear and (2) avoiding most of the systemic side-effects of glucocorticoids. a well-designed randomized trial was conducted in 2011 by rauch and his colleagues, which supported the non-inferiority in hearing outcomes of intratympanic therapy compared with oral prednisone in issnhl. however, the study was failed to reject the inferiority based on the 10-db non-inferiority standards in the subgroup analysis of issnhl with dizziness [9] . considering that few investigations have been carried out on progress and prognosis of issnhl-related vestibular dysfunctions after basic treatment, we designed this randomized, assessor-and analyst-blinded, controlled trial with two interventional arms, one is the oral glucocorticoid therapy group and the other one is the intratympanic glucocorticoid therapy group. our research hypothesis is that intratympanic methylprednisolone is superior to oral prednisone on vestibular function recovery of issnhl patients with vertigo. this protocol is reported in accordance with the standard protocol items: recommendations for interventional trials guidelines (spirit) (additional file 1) [10] . this study is designed as an 8-week, single-center, randomized, assessor-and analyst-blinded, controlled trial with two parallel interventional groups in a 1:1 allocation. patients will be recruited from outpatient clinics of the eye and ent hospital of fudan university in shanghai, qualified with well-trained doctors, staff, and required facilities for this clinical trial. patients who meet all of the following inclusion criteria will be considered eligible: patients who visit doctors from the outpatients and suspected of issnhl with vestibular dysfunction will be screened for eligibility. eligible patients who consent to participate will receive either oral prednisone or intratympanic methylprednisolone randomly in a 1:1 allocation. the randomization sequence will be generated through @random.org, an internet website (https:// www.random.org) producing true random sequence according to atmosphere noise. the concealed randomization sequence file will be constructed and kept in sequentially numbered, sealed, opaque envelopes by a staff member (zhao l.) in the eye and ent hospital of fudan university outside the study team. all the potential participants will be evaluated in strict chronological order of visiting time. when a patient is officially enrolled and numbered, the staff member will be contacted by telephone and open the corresponding envelope to find the randomized treatment for this patient. assessors in examination rooms and statistician analysts are not allowed to receive any information of the group allocation. the information of participants will be referred using research code among investigators, and their personal information (like name and contacts) will be kept confidential before, during, and after the trial. following randomization, baseline information of the participants in demographic and clinical characteristics will be collected, such as age, gender, nationality, occupation, date of onset, predisposition, initial symptoms, time of diagnosis, any treatments before enrolments, body mass index (bmi), and comorbidities. the objective vestibular function evaluated by sot, videonystagmography (vng), vhit, cvemp, and ovemp and the hearing outcome assessed by pta will be performed at baseline and at 4 and 8 weeks after randomization, while the subjective vestibular dysfunction feelings reflexed by dizziness handicap inventory (dhi) and visual analogue scale for vertigo (vas-v) and the tinnitus condition assessed by vas in tinnitus (vas-t, visual analogue scale for tinnitus) will be performed at baseline and at 1, 2, 4, and 8 weeks after randomization. caloric test is routinely included in vng. acoustic impedance and magnetic resonance imaging of the internal auditory canal (mri-iac) will be performed only once at the baseline examination to exclude the potential misdiagnosed ssnhl. once a participant is randomized, the treatment procedure starts immediately ( table 1 ). the participants in group 1 will receive oral prednisone 1 mg/kg/day (maximum daily dosage is no more than 60 mg) for 7 days, followed by a 7-day taper ( table 1 ). the patients are advised to take the medicine in 30 min before every breakfast, and not to divide the doses. the participants in group 2 will receive 7 intratympanic 40 mg/ml methylprednisolone injections in 14 days, one injection every other day. the otolaryngologists in charge of the injection work are asked to inject at the posterior superior quadrant and fulfill the tympanic cavity using operating microscopes, after lidocaine spray anesthesia. patients will be asked to keep supine position with the affected ear slightly up to 30°and avoid swallow during injection and in 30 min after the injection. the drug for injection is methylprednisolone sodium succinate for injection by pfizer manufacturing belgium nv. of all the participants, the length of treatment would be extended for another week if the change in hearing threshold (average db in pta) is less than 10 db, or average of pta is worse than 55 db in the patient's affected ear, under the participant's agreement. the salvage treatment regimen is 3 injections of 40 mg/ml methylprednisolone every other day. records and effects of the salvage treatments will be reported in the study results and evaluated according to both intention-totreat (itt) and per-protocol analyses. for those with severe vertigo attacks, drugs for symptom control like mannitol or diazepam can be used temporarily. in table 2 , criteria are listed in detail to distinguish the central vestibular system (cvs) compensation and peripheral vestibular system (pvs) restoration according to the following evidence: 1) sot is a measurement for dynamic and static posturography, which may figure out the different roles of the somatosensory, visual, and vestibular systems. the vestibular scores in sot will help us to distinguish peripheral function self-restoration from cvs compensation. 2) the caloric test has been used to evaluate the lateral semicircular canal function with a good sensitivity [11] . in the caloric test, unilateral weakness (uw), directional preponderance (dp), and spontaneous nystagmus (spn) are three parameters to judge the different phases of central vestibular compensation. uw presents at all three phases of acute injury, static compensation, and dynamic compensation phase and dp presents at the acute injury phase and static compensation phase, while spn only presents at the acute injury phase [12] . meanwhile, the caloric test results of complete function restoration in pvs should be the same as those in normal individuals: absence of uw, dp, or spn. 3) vhit can be employed for evaluating horizontal and vertical semicircular canals and has been taken as a specific indicator of peripheral vestibular function [13, 14] . the decreased gains and corrective saccades are signs of the corresponding semicircular canal dysfunction. 4) cvemp is a widely used measurement for assessing the saccular and inferior vestibular pathway functions, while ovemp for evaluating the utricular and superior vestibular pathway functions [15] . based on the integrity of neural pathways, we may reasonably assume that if the dysfunction of otolith organ and its afferent pathway has not recovered in our participants, the compensation effects of cvs will not bring a normal vemp result [14, 16] . here come two possible patterns in vestibular dysfunction recovery of issnhl. the first pattern (pattern a) is that the patients undergo well central vestibular compensations with no recovery of pvs function. in this pattern, patients may show a quite normal ability of balance evaluated by subjective complaints, dhi or vas-v; however, since the peripheral vestibular organs remain dysfunctional, vestibular test battery (i.e., sot, caloric tests, vhit, and vemps) will come out with abnormal results. the second possible pattern (pattern b) is that the pvs injuries are completely or partially restored in the patients. in this condition, not only the subjective complaints will disappear, but also the objective vestibular test results will get back to normal, or at least less abnormal. the methodology details of the following tests have been reported before [17] . if the patient's weight is less than 50 kg, the administration will be stopped after the day with < 10 mg prednisone administered, for example, a patient weighs 45 kg will stop receiving glucocorticoids at the 13th day b one day early or late of injection is allowed for practicality . six sensory test modes are performed with changing supports and visual conditions. the results are analyzed comprehensively to give a score for each sensory system (somatosensory, visual, and vestibular systems) and a composite score. results are considered abnormal when the score is lower than the age-specific normative data. caloric test we deliver the caloric test using the air caloric irrigator system of ics aircal (gn otometrics, taastrup, denmark) and record eye movements using videonystagmography (vng) of synapsys vng ulmer (synapsys, inc. marseille, france). patients are placed in a supine position in a darkroom, with the head flexed at 30°. the temperature of the warm and cool air is 50°c and 22°c, respectively. the unilateral weakness (uw) and directional preponderance (dp) are used to quantify the difference between the caloric responses of the two ears. the abnormal caloric result is defined as an absolute value of uw% greater than 22% and/or an absolute value of dp greater than 27%. vhit ics impulse system (gn otometrics, taastrup, denmark) will be used for vhit in this study. the examiner performs head impulses (150 to 200°/s peak head velocity) randomly in unpredictable timing and direction in the plane of each canal (the horizontal, anterior, and posterior semicircular canal), and at least 15 impulses for each side are acquired. the software analysis algorithm calculates the vestibular-ocular gain. normal gain is defined as > 0.8 for the lateral canals and > 0.7 for the vertical canals. the pathological saccade is defined as refixation saccades categorized as either covert saccades (occurring during a head movement) or overt saccades (occurring after a head movement) [18] . the result of a semicircular canal will be considered abnormal when there are pathological saccades and the gain is out of normal range. vemp the recording device of both cvemp and ovemp is the bio-logic navigator pro (natus medical inc., san carlos, usa). cvemp patients are asked to lie in supine position on a bed, with head raised to 30 to 45°away from the bed during recording to ensure good muscle tone. electrodes are placed as operation manual. air-conducted sound with 500-hz short tone bursts (2 ms rise/fall time and 2 ms plateau time) are presented through insert headphones as stimuli. the starting stimulus intensity is 95 db nhl and decreases by 5 db nhl each time until the meaningful wave is undetectable. the lowest intensity with a characteristic waveform is defined as threshold. the result will be considered abnormal if one of the following conditions is met: (1) the amplitude asymmetry ratio (ar) is more than 37%; (2) the cvemp meaningful waveform (where the waveforms with positive-negative-positive peak, p1-n1-p2, could be recognized and well repeatable) is absent at 95-db nhl stimulus or the threshold is out of range compared with age-specific normative data; (3) delayed response: the cvemp threshold shift is out of the range: p1 range 15.66 ± 7.22; n1 range 23.42 ± 5.18 (the mean of normal range ± 2 × sd) [19] [20] [21] [22] . ovemp the recording device, software, and stimuli are the same as those in cvemp. the patients remain lying supine and are asked to look upward (approximately 30°a bove the horizontal plane) during recording. electrodes are placed as reported in previous studies [17] . the recording procedure is the same as that in cvemp, and the lowest intensity with a characteristic waveform is defined as threshold. we define the abnormal result of ovemp as (1) absence of meaningful waveform (where the waveforms with negative-positive peak, n1-p1, could be recognized and well repeatable); (2) the threshold out of range compared with age-specific normative data; and (3) amplitude asymmetry ratio (ar) ≥ 40% [19, 20] . all examinations will be performed by trained physicians skilled at neuro-otological tests. is a self-assessment questionnaire with 25 items, and the reliability of the chinese version has been verified [23] [24] [25] [26] . the 25 items can be divided into 3 subscales: physical, emotional, and functional aspects, and the total scores range from 0 to 100. the higher the score, the more severe the dizziness is in the patients. visual analogue scale is a universal psychometric scale evaluating subjective attitudes [27, 28] . when applied in vertigo or tinnitus (vas-v or vas-t), respondents specify their level of vertigoes or tinnitus by indicating a position along a continuous line between two endpoints without marked scale. a score from 0 to 10 will be made based on the length of the line. the higher the score, the more severe the symptom is. to evaluate the recovery of vestibular function, we set the recovery rates of the whole battery of vestibular function tests (sot/caloric test/vhit/vemps) as the primary outcome, which is the proportion of patients whose abnormal results of vestibular function tests at baseline recover to normal at 4-/8-week follow-up: in this study, we define a 10-db pta criterion as clinically significant difference based on a previous rct [9] . 3) safety: rates of study-related adverse events (aes), such as short-term systemic use of glucocorticoids related saes and aes, and intratympanic injectionrelated aes. the study included 5 follow-up visits in total: a baseline visit to sign the consent and to record the baseline information, 2 visits during treatment interval to record subjective vestibular questionnaires (dhi, vas-v, and vas-t) and hearing outcomes (pta) and to monitor treatment safety outcomes, and 2 follow-up visits at 4 weeks and 8 weeks to assess hearing and vestibular functions and monitor safety outcomes. to optimize examination resources and reduce burden of examiners, among all five vestibular function tests (sot, caloric test, vhit, cvemp, and ovemp), only those with previous abnormal results will be repeated at follow-up visits. the study flow diagram is shown in fig. 1 , and the spirit figure of enrolment, interventions, and assessments is presented in table 3 . any untoward medical occurrences with unfavorable symptoms in the participants are defined as adverse events (aes). ae is not necessarily to have a causal relationship with the treatment. if the aes are lifethreatening, result in death, persistent, and significant disability or incapacity, or make the participants' hospitalization, we define them as serious adverse events (saes). the investigators will routinely ask the patients if there have been any unexpected symptoms. studyrelated and non-study-related aes will be recorded in the patient's clinical history by doctors in clinics and then reported to a trial investigator (yu h.) . participants experiencing aes will be followed up until the end of the events or the end of the trial. any saes during this trial will be reported to the trial steering committee table 3 the spirit figure of enrolment, interventions, and assessments vng videonystagmography which includes the caloric test, mri-iac magnetic resonance of the internal auditory canal *a follow-up test is only repeated when the previous test results in abnormal findings (tsc) and adverse drug reaction administration (adra) of the eye & ent hospital of fudan university within 48 h at learning of the event. we list some possible study-related aes here: 1) short-term systemic use of glucocorticoids related saes: fracture, sepsis, and venous thromboembolism [29] ; 2) short-term systemic use of glucocorticoids related aes: blood glucose problem, appetite change, sleep change, weight change; and 3) intratympanic injection-related aes: ear pain, ear infection, tympanic membrane perforation, and worse vertigo after injection. the participants will be informed of the right to withdraw from the study at any time after consent. the enrolled participants who are found ineligible later, lost to follow-up, or withdraw consent for any reason will be regarded as withdrawal. as for those who decided not to receive the protocol intervention, we will ask them if they would like to continue with the follow-up visits and if they agreed, their results will be regarded as variation other than withdrawals in itt analysis. we provide an online wechat and telephone contacts to all the participants for timely communication and health education, which will promote the participants' retention and adherence to the intervention protocols. furthermore, we optimized the follow-up process by setting a specialty clinic for ssnhl, minimizing the waiting time, and waiving extra examination and treatment fees. we decide not to set blindness of the interventions to patients and doctors, because that setting blindness to patients and doctors will need placebo injections to some of the participants, which may bring unnecessary pain and tympanic membrane perforation risk to the patients. the specialists in test rooms and statistical analysts will be kept blinded during the trial until the statistical analyses are done. a data monitoring committee (dmc) has been established to store, monitor, and check the authenticity, security, and integrity of the database. all members in the dmc are independent of the study sponsors and declared no competing interests. the dmc will periodically review the accumulated data and communicate the problems of its deliberations to the study team if necessary. the frequency of the interim analyses will be judged by the chair of the dmc, based on the consultation with the tmc. we anticipate that there might be 2-3 interim analyses before the final analysis. in our previous studies, we reported the poor indicator of the vestibular system lesion patterns in ssnhl and put forward that the incidence of vestibular dysfunction [30, 31] . however, we only found the existence of vestibular recovery in clinical case reports [16] . due to lack of previous reported data on changes of vestibular function test results, this study sample size was calculated based on data from preliminary clinical practice in our hospital. among patients who were diagnosed as issn hl and treated with oral prednisone, the recovery proportion of the vestibular function tests (measured by sot, caloric test, or vemps) was 0.25, while the recovery proportion among those treated with intratympanic glucocorticoids was approximate 0.64. using the program of g*power 3.1 for fisher's exact test, we calculated a sample size of 30 per arm with 80% power at a two-tailed 5% level of significance [32] . to allow for 20% dropout, 36 participants per arm will be needed. for the outcomes, categoric variables will be expressed as rates, while numerical variables as the mean ± sd. baseline data will be compared between two groups with a chi-squared test for dichotomous samples and student's t test or mann-whitney u test for two independent samples where appropriate. for comparisons of recovery in 4 and 8 weeks from baseline, the recovery rates of vestibular function tests will be calculated by chi-squared tests, and logistic regression adjusts for potential confounders like age, initial pta, the number of involved vestibular organs, mri-iac results, and other characteristics, while the numerical variables like uw of the caloric test, pta, and scores in dhi, vas-v, and vas-t will be calculated by mixed-model with repeated measures analyses of variance (anova), with group and time as fixed effects and subject as a random effect, controlling for the potential confounders. between two intervention groups, the chi-squared test will be used to analyze the difference for dichotomous outcomes (e.g., recovery rates) and student's t test for two independent samples or mann-whitney u test where appropriate. a value of p < 0.05 of two-sided is considered statistically significant. we will calculate relative risk (rr) with corresponding 95% confidence intervals to compare dichotomous variables, and mean difference (md) for continuous variables. an itt analysis and a per-protocol analysis will be both performed at each outcome. for the missing data in itt analyses, if there is any, multiple imputation methods will be used. up-to-date versions of spss (spss, chicago, il, usa) will be used to conduct analyses. a statistician from the medical college of fudan university will perform the analyses. not until the statistician complete the analysis, will he be unblinded to the group allocations and the study hypotheses. all data sent to the analyst will be anonymized, and the study groups will be coded as groups a and b. this protocol and the template informed consent forms have been reviewed and approved by the institutional review board (irb) and the ethical committee of eye & ent hospital of fudan university (reference number: 2017047). the tmc will make safety and progress reports to the irb at least annually and within 3 months of study completion. patients and the public were not involved in the design of this study. however, the study was initially discussed with issnhl patients' representative on how best to involve patients throughout the proposed project. finally, the study results will be informed to the public via peer-reviewed journals or academic conferences. vestibular dysfunction, commonly complained by patients as vertigo, dizziness, or lateropulsion, has been considered as a risk factor of profound hearing loss and poor prognosis [30] [31] [32] [33] [34] . recently, researchers made their efforts to specify the lesion patterns of the vestibular system in issnhl and proposed that the utricle and superior vestibular pathway is the most vulnerable vestibular site in issnhl, followed by the lateral semicircular canal and superior vestibular pathway [30] . severe vertigo and static imbalance markedly improve over a couple of days or weeks in most of patients, while some may suffer from long-term residual dizziness. recovery of peripheral vestibular function and central vestibular compensation might be involved in this process. vestibular function tests, such as sot, caloric test, vhit, and vemp, are effective and objective methods to distinguish restoration of peripheral vestibular function and compensation of the central vestibular. it has been reported that in a few cases of ssnhl, function of otolith organs reflexed by vemps was absent at onset and recovered or improved after weeks to months [16] . these cases suggested the role of peripheral vestibular function restorations. when peripheral vestibular injury is failed to recover by itself, the central compensation will take place. however, due to few previous researches in this field, the roles and proportions of central compensation versus peripheral recovery remain uncertain. we assume that appropriate treatments for issnhl may have favorable effects promoting the vestibular recovery process, as those in hearing outcomes. glucocorticoid therapy is currently a regular and standard treatment for issnhl according to guidelines [1, 35] . the plausible mechanisms include anti-inflammatory, immune-suppressive, and inner-ear-homeostasis-related gene regulative effects [36] . regrettably, with numerous studies of different evidence levels delivered in the past six decades, the effectiveness of glucocorticoids in treating issnhl remains uncertain. most of the rcts and meta-analyses on this topic claimed of disappointing results with little measurable improvements in glucocorticoids over placebo arms [37] [38] [39] . it is worth noting that many confounding factors like various regimens and administration of drugs, different time points of starting treatments, and different probable causes existed in these studies. few studies have focused on the effects of glucocorticoids in vestibular recovery of issnhl. taking the previous researches in acute unilateral vestibulopathy for reference, improvements have been found evaluated by vestibular function tests, the symptom loads, and dhi scores [40, 41] . hereby, we may speculate that glucocorticoids could possibly accelerate vestibular function recovery via restoration of the peripheral vestibular system. to assess the vestibular functions, we intend to perform a battery of vestibular function tests including (1) the sot for assessing static and dynamic posture control ability of somatosensory, visual, and vestibular systems distinguishingly and comprehensively; (2) the caloric test for evaluating horizontal semicircular canal functions and superior vestibular integrity; (3) vhit for evaluating functions of horizontal and vertical semicircular canals; and (4) cvemp for investigating the saccular function and the inferior vestibular pathway and ovemp for assessing utricular function and the superior vestibular pathway [11, 13, 15, 42, 43] . moreover, we plan to perform dhi and vas-v, two qualified and widely used subjective measurements, to assess the severity of symptoms and negative influence on patients' daily lives [25, 44] . in conclusion, our study will be the first to assess and follow the vestibular function conditions of issnhl up using a whole battery of vestibular function tests. based on our clinical practice experience, we hypothesize that the effects of intratympanic glucocorticoids will be superior to those of oral therapy in terms of the outcome measurements mentioned above. moreover, we expect that participants in the intratympanic group will experience more significantly reduced dhi scores, lessened vas-v scores, and better enhanced recovery of pta. the planned date of the first enrolment is 1 sep 2019. the estimated time required for recruitment is 12 months. the total duration of this study is expected to be 18 months, including statistical analysis and article writing. this protocol version number is ver.3. clinical practice guideline: sudden hearing loss (update) national institute on deafness and other communication disorders. nidcd fact sheet: sudden deafness accessed 15 systematic 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corticosteroids and related harms among adults in the united states: population based cohort study association of vertigo with hearing outcomes in patients with sudden sensorineural hearing loss: a systematic review and meta-analysis vestibular dysfunctions in sudden sensorineural hearing loss: a systematic review and meta-analysis gpower: a general power analysis program vertigo as a prognostic sign in sudden sensorineural hearing loss the relationship between hearing loss and vestibular dysfunction in patients with sudden sensorineural hearing loss society of otorhinolaryngology head and neck surgery, chinese medical association. guideline of diagnosis and treatment of sudden deafness (2015) corticosteroid therapy for hearing and balance disorders treatment of sudden sensorineural hearing loss: ii. a meta-analysis steroids for treatment of sudden sensorineural hearing loss: a meta-analysis of randomized controlled trials corticosteroid treatment of idiopathic sudden sensorineural hearing loss: randomized triple-blind placebocontrolled trial glucocorticoids improve acute dizziness symptoms following acute unilateral vestibulopathy methylprednisolone, valacyclovir, or the combination for vestibular neuritis characteristics and clinical applications of ocular vestibular evoked myogenic potentials learning effects of repetitive administrations of the sensory organization test in healthy young adults efficacy and safety of acupuncture for dizziness and vertigo in emergency department: a pilot cohort study publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to thank the patients for participating in the trial and our colleagues for supporting the study. supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04579-6.additional file 1. spirit checklist.additional file 2. case report forms template.additional file 3. adverse event forms template. this study was supported by the science and technology commission of shanghai municipality (grant number 184119551900), contact at +86-021-23111111. this funding source played no part in the study design and will not have any role in its collection, management, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication. during the study, the datasets used in the current study are available from the corresponding author on reasonable request. after the study, the results of this trial will be published in peer-reviewed journals and presented at national and/or international conferences. the study has been approved by the ethical committee of eye & ent hospital of fudan university (reference number 2017047-1), and informed consent will be obtained from all participants of this trial before participating; the model consent form is attached in crf in additional file 2. not applicable. key: cord-303322-d69o3z8d authors: chang, anne b; grimwood, keith; white, andrew v; maclennan, carolyn; sloots, theo p; sive, alan; mccallum, gabrielle b; mackay, ian m; morris, peter s title: randomized placebo-controlled trial on azithromycin to reduce the morbidity of bronchiolitis in indigenous australian infants: rationale and protocol date: 2011-04-14 journal: trials doi: 10.1186/1745-6215-12-94 sha: doc_id: 303322 cord_uid: d69o3z8d background: acute lower respiratory infections are the commonest cause of morbidity and potentially preventable mortality in indigenous infants. infancy is also a critical time for post-natal lung growth and development. severe or repeated lower airway injury in very young children likely increases the likelihood of chronic pulmonary disorders later in life. globally, bronchiolitis is the most common form of acute lower respiratory infections during infancy. compared with non-indigenous australian infants, indigenous infants have greater bacterial density in their upper airways and more severe bronchiolitis episodes. our study tests the hypothesis that the anti-microbial and anti-inflammatory properties of azithromycin, improve the clinical outcomes of indigenous australian infants hospitalised with bronchiolitis. methods: we are conducting a dual centre, randomised, double-blind, placebo-controlled, parallel group trial in northern australia. indigenous infants (aged ≤ 24-months, expected number = 200) admitted to one of two regional hospitals (darwin, northern territory and townsville, queensland) with a clinical diagnosis of bronchiolitis and fulfilling inclusion criteria are randomised (allocation concealed) to either azithromycin (30 mg/kg/dose) or placebo administered once weekly for three doses. clinical data are recorded twice daily and nasopharyngeal swab are collected at enrolment and at the time of discharge from hospital. primary outcomes are 'length of oxygen requirement' and 'duration of stay,' the latter based upon being judged as 'ready for respiratory discharge'. the main secondary outcome is readmission for a respiratory illness within 6-months of leaving hospital. descriptive virological and bacteriological (including development of antibiotic resistance) data from nasopharyngeal samples will also be reported. discussion: two published studies, both involving different patient populations and settings, as well as different macrolide antibiotics and treatment duration, have produced conflicting results. our randomised, placebo-controlled trial of azithromycin in indigenous infants hospitalised with bronchiolitis is designed to determine whether it can reduce short-term (and potentially long-term) morbidity from respiratory illness in australian indigenous infants who are at high risk of developing chronic respiratory illness. if azithromycin is efficacious in reducing the morbidly of indigenous infants hospitalised with bronchiolitis, the intervention would lead to improved short term (and possibly long term) health benefits. trial registration: australia and new zealand clinical trials register (anzctr): actrn12610000326099 we are conducting a dual centre, randomised, double-blind, placebo-controlled, parallel group trial in northern australia. indigenous infants (aged ≤ 24-months, expected number = 200) admitted to one of two regional hospitals (darwin, northern territory and townsville, queensland) with a clinical diagnosis of bronchiolitis and fulfilling inclusion criteria are randomised (allocation concealed) to either azithromycin (30 mg/kg/dose) or placebo administered once weekly for three doses. clinical data are recorded twice daily and nasopharyngeal swab are collected at enrolment and at the time of discharge from hospital. primary outcomes are 'length of oxygen requirement' and 'duration of stay,' the latter based upon being judged as 'ready for respiratory discharge'. the main secondary outcome is readmission for a respiratory illness within 6-months of leaving hospital. descriptive virological and bacteriological (including development of antibiotic resistance) data from nasopharyngeal samples will also be reported. discussion: two published studies, both involving different patient populations and settings, as well as different macrolide antibiotics and treatment duration, have produced conflicting results. our randomised, placebocontrolled trial of azithromycin in indigenous infants hospitalised with bronchiolitis is designed to determine whether it can reduce short-term (and potentially long-term) morbidity from respiratory illness in australian indigenous infants who are at high risk of developing chronic respiratory illness. if azithromycin is efficacious in reducing the morbidly of indigenous infants hospitalised with bronchiolitis, the intervention would lead to improved short term (and possibly long term) health benefits. trial registration: australia and new zealand clinical trials register (anzctr): actrn12610000326099 background worldwide, bronchiolitis is the most common acute lower respiratory tract infection (alri) in infants [1] [2] [3] . in the northern territory (nt, australia), alris are the most frequent reason for hospitalisation of young children (aged <5-years). alris are also the commonest cause of preventable deaths in indigenous infants (5 times that of non-indigenous) [4] . of alris, bronchiolitis (with or without pneumonia) is the most frequent reason for hospital admission in nt indigenous infants aged under 12-months [5] . despite this heavy burden of bronchiolitis in indigenous infants, currently no prospective studies have been published. our retrospective review of 101 infants hospitalised with bronchiolitis at the royal darwin hospital (darwin, northern territory) found that 33.7% of indigenous infants were readmitted within six-months of discharge from hospital [6] . as most were retrieved from remote communities, the impact of the illness, its costs and social dislocation were likely to have been substantial. recurrent alris are independently associated with the development of bronchiectasis [7] and reduced pulmonary function later in life [8] . low birth weight and pre-existing small lungs are important determinants of future lung function, but there is increasing evidence that events in early life are at least equally important determinants of adult pulmonary dysfunction [8] [9] [10] . the first few years of life are the most critical period [11] . thus events such as severe alris during this critical period are likely to have long term effects. australia-wide, hospitalisation rates of respiratory disorders among indigenous australians are second only to those for renal dialysis [12] . furthermore, we have previously documented that the severity of the hospitalised alri episode, as determined by oxygen requirement and duration of hospitalisation, was an independent risk factor for subsequent bronchiectasis [7] . in the northern territory (nt), bronchiectasis affects one in every 68 indigenous children, far exceeding that of cystic fibrosis (cf) in non-indigenous australian children (1 in 2857) [13, 14] . thus, any intervention that reduces bronchiolitis severity and/or risk of readmission for respiratory illness in indigenous infants may have both short term and potential long term benefits in our setting. bronchiolitis is characterised by extensive inflammation of the airways accompanied by increased mucous production and necrosis of airway epithelial cells. in paediatrics, bronchiolitis is a clinical diagnosis characterised by tachypnoea, wheeze and/or crepitations in infants following a preceding upper respiratory illness [1] . it is primarily caused by infection of the respiratory epithelial cells by a variety of viruses, especially respiratory syncytial virus (rsv). other viruses (adenovirus, influenza, parainfluenza, human metapneumovirus, rhinovirus) are also implicated and increasingly new viruses are being detected in association with this illness [15] . in addition, mycoplasma pneumoniae and chlamydia species are recognised increasingly as important contributors to the development of chronic lung disease and altered lung maturation [16] [17] [18] [19] . new treatable bacteria such as simkania negevensis (a chlamydia-like microbe) has been found in canadian inuit infants with bronchiolitis [20] . there are no published data on the nature or diversity of respiratory pathogens associated with bronchiolitis in indigenous australians infants. typically anti-microbials are not recommended in the routine management of bronchiolitis [1, 21] . while there are two rcts on macrolides for bronchiolitis, the single available rct on a non-macrolide anti-microbial was a negative study [22] . however in our setting, there are several reasons why anti-microbials may reduce the morbidity of hospitalised indigenous infants with bronchiolitis. colonisation of nasopharynx with bacteria is a known risk factor for childhood pneumonia [23] . indigenous infants not only have colonised nasopharynx very early in life (as early as aged 2-weeks), but the colonisation is also dense with common respiratory bacterial pathogens, notably streptococcus pneumoniae, haemophilus infleunzae and moraxella catarrhalis [24] . repeated micro-aspiration of nasopharyngeal secretions heavily laden with pathogenic bacteria during alri may overwhelm already compromised pulmonary defences, increasing the risk of a secondary pneumonia or other lower airway infection. indeed, indigenous infants are more likely to receive antibiotics for an episode of pneumonia diagnosed during an admission for bronchiolitis than non-indigenous infants nursed in the same paediatric unit [6] . macrolides are a class of antibiotics containing a macrocyclic lactone ring with excellent tissue penetration and antimicrobial activity against a broad range of gram positive and gram negative bacteria, including intracellular pathogens such as chlamydia. those with a 14-or 15-membered lactone ring also have several non-antimicrobial properties that have been studied extensively in-vitro and in experimental models and, to a lesser extent, in humans [25] . one of these effects is modulation of the immune response. the immune modulating properties of macrolides make them attractive candidates for treating inflammatory airways diseases. the two published [26, 27] placebo-controlled rcts on macrolides for rsv-bronchiolitis reported contradictory results. in a small turkish study of 21 hospitalised infants with moderate to severe bronchiolitis, 3-weeks of daily clarithromycin significantly reduced severity of illness (oxygen use, hospital stay) and risk of hospital readmission for respiratory illness during the next 6 months [26] . however in another larger study involving 71 infants from the netherlands, 3-days of azithromycin was not efficacious in infants hospitalised with bronchiolitis [27] . the difference in outcomes seen in the two trials may be related to the dose or length of treatment, chance, or heterogeneity of the study populations. infants in turkey are more likely to have concomitant bacterial infection compared to an affluent european group and moreover in turkey, post-infectious childhood bronchiectasis remains an important health problem [28] . the populations also differed in age. the european study included infants up to 24-months of age, whereas the turkish study involved only infants aged <7-months [26, 27] . clearly, a well designed rct on the efficacy of macrolides to reduce the burden of bronchiolitis in a population at high risk of acute and chronic respiratory disease would be beneficial. our primary research question is: amongst hospitalised indigenous infants with bronchiolitis, does azithromycin (compared to placebo) improve clinical outcomes (length of stay in hospital and duration of oxygen supplementation)? our primary hypothesis is that: the anti-microbial and anti-inflammatory properties of the macrolide, azithromycin, will improve the clinical outcomes of indigenous infants hospitalised with bronchiolitis. our secondary aims are: 2. to determine the effect of azithromycin on readmissions into hospital within 6 months of treatment; 3. to assess the short-term impact of azithromycin on macrolide resistance patterns of respiratory bacterial pathogens in the nasopharynx; and 4. to describe the point prevalence and diversity of respiratory viruses, mycoplasma pneumoniae and chlamydia species using sensitive molecular diagnostic techniques. we are conducting a parallel group, double-blind placebo rct (with concealed allocation) to assess the impact of additional treatment with azithromycin in indigenous infants admitted to two regional hospitals (darwin, northern territory and townsville, queensland) with bronchiolitis. our study plan is summarised in figure 1 . the inclusion criteria are: baseline data, nps-1 1. indigenous infants (aged ≤ 24-months) admitted to one of our hospitals (darwin and townsville) with a clinical diagnosis of bronchiolitis. in the absence of an international standardised diagnosis of bronchiolitis, [29, 30] the accepted australian clinical diagnosis is used (tachypnoea (respiratory rate ≥60/min in infants aged <2-months, ≥50/min if 2-12 months, and >40/min if 13-24 months), with wheeze or crackles); [31, 32] and 2. recruited and consented within 24-hours of presentation to the hospital for the illness. exclusion criteria: admission into intensive care, macrolide therapy contraindicated (e.g. liver dysfunction, hypersensitivity), presence of diarrhoea (stools of increased watery consistency and more than two stools above usual stooling frequency), received macrolides (in last 7-days), or clinical and radiological features consistent with a primary diagnosis of pneumonia, [33] at time of randomisation. at each site, the site-specific study nurse visits the wards twice daily to screen all newly admitted infants. a standardised collection form is used to collect clinical data (see below) and hospital outcomes associated with the bronchiolitis episode. all infants are managed according to a standardised protocol. this has been used at the royal darwin hospital since 2008. the protocol outlines when supplementary oxygen is prescribed (sp0 2 <94%) and reduced, and when nasogastric feeds or intravenous fluids are used. enrolled infants may receive additional therapies (other than macrolides) at the discretion of the attending paediatrician. if eligibility is fulfilled and after informed consent has been obtained, the infant is randomised to receive either a single, oral liquid dose of azithromycin syrup (30 mg per kg) or an equivalent volume of placebo. medication is given within 24-hours of hospitalisation. infants randomised to the intervention arm of the study will receive additional treatment doses of azithromycin syrup (30 mg per kg) on day-7 and day-14. those randomised to the control arm receive an equivalent volume of the placebo syrup. the later doses will be either supervised by study nurses or administered by families with phone support on the day the medication is due. final clinical follow up will occur in the local health clinic on day-21 (or closest available date from day 20 to 24). the randomisation sequence was computer generated and used permutated blocks (4 or 6 participants per block). the allocation sequence is concealed at all times throughout the study. the computer generation and allocation were performed by a statistician, external to the study team. upon enrolment, an infant is assigned to the next number on the appropriate stratified list. each unique number is assigned to one of the eight treatment alphabets (see below). treatment groups are stratified by age (≤6 or >6 months), site (darwin or townsville) and requirement (yes or no) for oxygen at point of randomisation. the importance of excluding older children and stratifying at the 6 month age group is well described [30, 34] . a placebo medication ensures that all children, carers, researchers, hospital staff, and clinic staff are blinded to treatment group until analyses of the data. the placebo medication has been specifically manufactured by the institute of drug technology (idt) australia limited (melbourne, vic) which has a similar taste and colour to azithromycin. the azithromycin medications were repackaged by idt. thus both the azithromycin and placebo are in identical opaque bottles and sealed with an aluminium foil. for both, equal volumes of water are added using a syringe and needle by punching the seal. eight alphabets (n, o, p, q, r, s, t, u) were used for the bottles of azithromycin and placebo medications (4 alphabets each). we used multiple alphabets rather than sequential numbers on the bottles to allow storage of extra bottles of trial medications in clinics for the day-7 and day-14 doses. this was necessary in the context of our study setting (children mainly from remote indigenous communities), to enhance availability and administration of trial medications once the child has been discharged from the hospital. all data are recorded on standardised forms. demographic information (age, gender, region, birth details, smoke exposure, breast feeding, household size, etc) and medical history are obtained from the primary caregiver and the medical charts. the primary and secondary outcome measures (see below) are monitored twice daily until the hospital admission's end-point is reached (ready for respiratory discharge, defined as >16-hours without supplemental oxygen and infant is feeding well). clinical assessment data include oxygen requirement and level, physiological measurements for clinical severity score (respiratory rate, accessory muscle use, degree of wheeze), [27] other physiological measurement (temperature, heart rate), requirement and duration of other therapies required (intravenous fluids, nutritional support, antibiotics), ear examination findings (signs of suppuration) and subsequent pneumonia (diagnosed by the independent treating 'blinded' paediatrician). in addition, the results of routine investigations (full blood count and chest radiographic findings) are recorded. on day-21, the presence of cough, wheeze and auscultatory abnormality on clinical review are documented. adverse effects (vomiting, diarrhoea, rash) are also documented. a single nasopharyngeal swab (nps) specimen for respiratory virus and other potentially important respiratory pathogen (m. pneumoniae, chlamydia spp) testing is collected from each subject at enrolment. in addition, nps is repeated before hospital discharge for bacterial culture and antibiotic susceptibility testing, as per our laboratory research protocol (see below) [35, 36] . culturing, identifying and serotyping common respiratory bacteria from nps is an established technique in our laboratory at menzies in darwin [35] . swabs are stored in smggb at -80°c before being batch processed for typical respiratory bacterial pathogens, notably h influenzae and non-typeable h influenzae, m. catarrhalis and s. pneumoniae. batches of swabs are thawed and 10 μl aliquots cultured overnight on selective media at 37°c in 5% co 2 . growth of s. pneumoniae, h. influenzae and m. catarrhalis is recorded and confirmed. four isolates each of s. pneumoniae and h. influenzae and two isolates of m. catarrhalis per positive swab are tested for anti-microbial resistance and stored [35, 37] . s. pneumoniae isolates are serotyped using the quellung method (antisera from statens serum institute, denmark). in addition to routine susceptibility testing using the calibrated dichotomous susceptibility (cds) disc diffusion method, azithromycin minimum inhibitory concentration (mic) will be determined using etest (ab biodisk, sweden) if the azithromycin disc annulus is less than 6 mm. for s. pneumoniae, the penicillin mic is determined for penicillin non-susceptible isolates (oxacillin and/or penicillin disc annulus <6 mm) and for h. influenzae, the ampicillin mic is determined for isolates if the ampicillin disc annulus is less than 6 mm. interpretive criteria (csli breakpoints) used for s. pneumoniae are penicillin non-susceptible mic > 0.12 μg/ml, azithromycin resistant mic ≥ 2 μg/ml, and for h. influenzae, ampicillin resistant mic ≥ 4 μg/ml, azithromycin resistant mic > 4 μg/ml. beta-lactamase activity will be determined for h. influenzae and m. catarrhalis isolates. our previous methods will be utilised [15, 38, 39] . nps are frozen at -80°c. upon thawing nucleic acids will be extracted from 0.2 ml of each nps specimen using the high pure viral nucleic acid kit (roche diagnostics, australia), according to the manufacturer's instructions. mono-specific pcr and reverse transcriptase pcr (rt-pcr) method will be used to detect mycoplasma pneumoniae, coronaviruses, bocavirus and human metapneumovirus (hmpv), whereas multiplex pcr and rt-pcr was used to detect adenovirus, parainfluenza (1, 2 3), influenza (a and b) , and respiratory syncytial virus (rsv). all these methods have been previously validated in our viral laboratory at the royal children's hospital, brisbane. participation is complete when day-21 outcomes have been obtained. other exit points are: intolerance to the trial medications requiring withdrawal from study (as deemed by the treating paediatrician who is not directly connected to the study team). (i) length of stay (los) for respiratory illness in hospital-defined as time from admission to time 'ready for discharge' for respiratory care. 'ready for discharge' means normoxic (sp0 2 consistently >94% in air for >16hrs) and feeding adequately; and (ii) duration of supplemental oxygen required. 'ready for discharge' for respiratory care differs from length of hospitalisation as discharge from hospital may be delayed because of social or transport factors especially in children from remote communities. the major secondary outcome is readmission for respiratory illness (within 6-months of discharge from hospital). minor outcomes during hospitalisation: clinical severity score, [27] additional use of antibiotics, and episodes of suppurative otitis media and development of pneumonia. the day-21 outcomes are: presence of cough, wheeze, abnormal auscultatory chest signs and suppurative otitis media. we will also analyse all clinical outcomes in the following pre-determined sub-groups: (i) age ≤ 6-months; and (ii) presence of bacterial respiratory pathogens that are resistant to macrolide antibiotics. (i) identification of respiratory viruses and bacterial pathogens and (ii) antibiotic resistance to penicillin and macrolides. we plan to enrol 200 indigenous infants. in our retrospective study, [6] the mean los in indigenous infants with bronchiolitis at rdh was 96 (sd 24) hours. the mean duration of supplemental oxygen requirement in indigenous infants with bronchiolitis was 36 (sd 14) hours. for a mean difference of 24-hours in los between groups (power = 90%, α = 5%) the required sample size is 23 per group. the numbers to detect a 12-hour difference in supplemental oxygen requirement is 30 per group. these are large effect sizes but more conservative estimates than seen in the turkish study [26] . in that study, [26] the difference between groups was 30-hrs for los and 31-hours for supplemental oxygen requirement. assuming similar effects, a sample size of at least 100 in each sub-age group is also sufficient for an a-priori subgroup analysis based on age (power of 90% and 2-tailed α of 5%). if the effects are smaller, we will have an 80% power to detect a difference of 10hours in los in all infants and an 80% power to detect a difference of 14-hours in los in the ≤6-months age group. we do not believe that smaller benefits than this would be sufficient to change clinical practice. for the most important secondary outcome (readmission rate for a respiratory illness within 6-months of discharge), the power of our study to detect a reduction from 30% to 10% is 95% (5% significance). this is a large effect but consistent with the reduction described in the turkish study (75% reduction) [26] . at 80% power we will be able to detect a reduction in readmission rates from 30% to 13%. for our other secondary outcomes, accurate sample size estimations are not possible given the lack of any relevant data. data will be reported and presented in accordance with the updated consort criteria [40] . children will be analysed according to allocation status (regardless of subsequent management). an interim analysis is planned and the data safety and monitoring committee will determine if the study should be ceased should superiority of azithromycin be identified after 70% of sample size is achieved. the primary outcomes (los and duration of supplemental oxygen requirement) will be compared between infants receiving placebo or azithromycin using unpaired student's t-tests or mann-whitney tests (depending on normality of distribution). although we expect randomisation to equally distribute potential confounding factors between each of the groups, we will examine the distribution of known confounders between groups (eg. birth weight, smoke exposure status in-utero and postnatal, breast feeding, etc). should baseline data differ between groups, regression will be used to check that the primary outcomes are not affected by this chance finding. an a-priori sub-analysis will compare infants aged ≤ 6months with those aged >6-months. when examining the efficacy of azithromycin at reducing readmission rate for respiratory illness (secondary aim-2), the odds ratio (or) between groups will be calculated. the or will also be used to compare additional antibiotic use between groups. the number needed to treat (nnt) (for benefit), 95% ci will be described if any significant differences are found. if significant, nnt for harm will be calculated for adverse events. for secondary aim-3 (short-term impact of azithromycin on macrolide-resistance of pathogens in nps cultures): the proportions of children with penicillinnon-susceptible s. pneumoniae and macrolide-resistant h. influenzae spp and m. catarrhalis before and after trial medications will be compared using ors and 95% ci. descriptive data will be utilised for secondary aim-4 (point prevalence of respiratory viruses and other respiratory pathogens). the acute lower respiratory tract infections are the commonest cause of hospitalisation and potentially preventable deaths in indigenous infants [4] . bronchiolitis in indigenous infants is more severe than bronchiolitis in non-indigenous infants [6] . there are higher readmission rates and an increased risk of ongoing respiratory morbidity (including chronic suppurative lung disease) in indigenous infants [7, 41] . this may be due to an increased likelihood of recurrent infections and virusbacteria interactions from an early age (as early as aged 2-wks) along with heavy bacterial colonisation of the nasopharynx [36] . despite bronchiolitis being the most common cause of alris in infants resulting in hospitalisation, there are no published prospective studies of this illness in australian indigenous infants. two small clinical trials have studied macrolides in bronchiolitis, but with contradictory results. our population setting is more closely related to the turkish study [26] where a beneficial effect for macrolides was shown. this is in contrast to the negative findings of the dutch study [27] in an affluent urban setting. our proposed double-blind rct will determine if azithromycin is an effective additional treatment in indigenous infants hospitalised with bronchiolitis. it will also determine whether in the ensuing 6 months it will prevent hospital readmissions from respiratory illnesses, which potentially reduces the likelihood of chronic lung dysfunction [7] in this high-risk population. azithromycin was chosen over other macrolides because of its prompt and potent anti-inflammatory effects as well as its 30-40 hours half-life in children, which permits once weekly dosing [42] . the possible anti-viral effects is also attractive [43] . an important safety component of the current study is to monitor for antibiotic resistance in potential respiratory bacterial pathogens colonising the nasopharynx. for the first time in this population, we will determine the nature and diversity of respiratory viruses, mycoplasma, chlamydia and chlamydia-like species in association with cases of bronchiolitis requiring hospital admission. the range of organisms includes newly discovered viruses, [44] and treatable bacteria that may contribute to chronic lung dysfunction. m. pneumoniae and chlamydia species are increasingly recognised as important contributors to development of chronic lung disease and altered lung maturation [16] [17] [18] [19] . our study addresses a large clinical research gap for an important and common cause of hospitalisation in indigenous infants. if the intervention is successful, it would lead to improved short term (and possibly long term) health benefits. conclusive results would produce changes to evidencebased standard treatment guidelines in our region and those produced for similar populations nationally and internationally. finally, the intervention would also offer the possibility of preventing (or reducing) the high rates of long-term respiratory dysfunction seen in australian indigenous children and adults. risk factors for bronchiectasis in indigenous children include recurrent hospitalisation for alris and severity of previous arlis (measured by duration of stay and requirement for oxygen supplementation during hospitalisation) [7] . in the context of the high burden of bronchiectasis in our setting, we considered that the most important outcomes are los, requirement for oxygen supplementation during hospitalisation and readmission within a 6-month period. length of hospitalisation is a common outcome measure in studies on bronchiolitis. however in our setting, hospitalised children often come from remote comunities and may have multiple co-morbidities [33] that influences their discharge. thus we used los defined in accordance with 'ready for respiratory discharge'. our study only addresses infants hospitalised for bronchiolitis. the impact of variable presentation particularly that related to the potential influence of azithromycin's acute immune modulation effect is a limitation of our study. however our study design minimises the impact of variable presentation by: (a) standardising our inclusion criteria, (b) limiting enrolment to within 24 hours of hospitalisation; (c) adopting a strategy (double blind, placebo controlled, allocation concealed methodology) that would theoretically distribute any effect equally between groups. additionally in the event that differences in baseline data between groups are found, we will use statistical methods (multivariate analysis) to adjust as required. in summary, given the very high burden of bronchiolitis in indigenous infants (the age when lung growth is most critical post-natally), and the association between alri and future lung dysfunction, our rct on azithromycin in indigenous australian infants hospitalised with bronchiolitis has the potential to have both short term gains and a long-term benefit for reducing morbidity of respiratory illness. subcommittee on diagnosis and management of bronchiolitis: diagnosis and management of bronchiolitis predicting 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indigenous children hospitalised with episodes of lower respiratory tract infection: a randomised controlled trial how should we study responses to treatment in children with bronchiolitis? respiratory bacterial pathogens in the nasopharynx and lower airways of australian indigenous children with bronchiectasis streptococcus pneumoniae and noncapsular haemophilus influenzae nasal carriage and hand contamination in children: a comparison of two populations at risk of otitis media random colony selection versus colony morphology for detection of multiple pneumococcal serotypes in nasopharyngeal swabs the impact of viral respiratory infection on the severity and recovery from an asthma exacerbation newly identified respiratory viruses in children with asthma exacerbation not requiring admission into hospital consort 2010 statement: updated guidelines for reporting parallel group randomised trials respiratory morbidity in central australian aboriginal children with alveolar lobar abnormalities once-weekly azithromycin in cystic fibrosis with chronic pseudomonas aeruginosa infection azithromycin induces anti-viral responses in bronchial epithelial cells evidence of human coronavirus hku1 and human bocavirus in australian children randomized placebo-controlled trial on azithromycin to reduce the morbidity of bronchiolitis in indigenous australian infants: rationale and protocol we thank the research staff (lesley versteegh, clare wilson, nerida jacobsen, susan pizzutto and amber revell) for facilitating the study, joseph mcdonnell for generating the randomisation sequences and jana lai for assistance with labelling the bottles. we are also grateful to members of the indigenous reference group of the child health division at menzies for supporting this study and for over-seeing the cultural aspects. we also thank drs ka o'grady, alan isles, alan ruben and william frischman for voluntarily providing their time in their participation in the study's data safety monitoring committee. we are also very appreciative to the channel 7 children's foundation and the financial markets foundation for children for funding the preliminary study that provided us with essential pilot data for our successful nhmrc grant submission. funding study is funded by a 3-year australian national health and medical research council (nhmrc) project grant (605809). abc is supported by a nhmrc fellowship (545216). authors' contributions ac conceived the study, and participated in its design and coordination and drafted the manuscript. pm, kg, ts, aw, as, cm participated in its design, analysis plan and submission to the nhmrc. gm participated in initiating and running the project and im in the viral analysis plan. all authors read and approved the final manuscript. the authors declare that they have no competing interests. key: cord-004450-daxz9yhp authors: haeberle, helene; prohaska, stefanie; martus, peter; straub, andreas; zarbock, alexander; marx, gernot; zago, manola; giera, martin; koeppen, michael; rosenberger, peter title: therapeutic iloprost for the treatment of acute respiratory distress syndrome (ards) (the thilo trial): a prospective, randomized, multicenter phase ii study date: 2020-03-04 journal: trials doi: 10.1186/s13063-020-4163-0 sha: doc_id: 4450 cord_uid: daxz9yhp background: acute respiratory distress syndrome (ards) is caused by rapid-onset (within hours) acute inflammatory processes in lung tissue, and it is a life-threatening condition with high mortality. the treatment of ards to date is focused on the prevention of further iatrogenic damage of the lung rather than the treatment of the initial inflammatory process. several preclinical studies have revealed a beneficial effect of iloprost on the control of pulmonary inflammation, and in a small number of patients with ards, iloprost treatment resulted in improved oxygenation. therefore, we plan to conduct a large multicenter trial to evaluate the effect of iloprost on ards. methods: the therapeutic iloprost during ards trial (thilo trial) is a multicenter, randomized, single blinded, clinical phase ii trial assessing the efficacy of inhaled iloprost for the prevention of the development and progression of ards in critically ill patients. one hundred fifty critically ill patients suffering from acute ards will be treated either by nebulized iloprost or nacl 0.9% for 5 days. blood samples will be drawn at defined time points to elucidate the serum levels of iloprost and inflammatory markers during treatment. mechanical ventilation will be standardized. in follow-up visits at days 28 and 90 as well as 6 months after enrollment, functional status according to the barthel index and a health care-related questionnaire, and frailty (vulnerable elders survey) will be evaluated. the primary endpoint is the improvement of oxygenation, defined as the ratio of pao(2)/fio(2). secondary endpoints include 90-day all-cause mortality, sequential organ failure assessment scores during the study period up to day 90, the duration of mechanical ventilation, the length of intensive care unit (icu) stay, ventilator-associated pneumonia, delirium, icu-acquired weakness, and discharge localization. the study will be conducted in three university ards centers in germany. discussion: the results of the thilo trial will highlight the anti-inflammatory effect of iloprost on early inflammatory processes during ards, resulting in the improvement of outcome parameters in patients with ards. trial registration: eudra-ct: 2016-003168-37. registered on 12 april 2017. clinicaltrials.gov: nct03111212. registered on 4 june 2017. acute respiratory distress syndrome (ards) is defined as pulmonary compromise with bilateral pulmonary infiltrates associated with moderate to severe hypoxemia [1] . the public health impact of ards is considerable, and it is estimated that approximately 75,000 cases of ards occur annually in germany. the estimated mortality ranges from 26 to 51% and depends on the severity of the associated hypoxemia [2] . patients surviving ards treatment also show reduced functional capacity in their everyday life following hospitalization [3, 4] . therefore, there is a pressing need to develop further ards treatment strategies with a view to ultimately improving patient outcomes. the bilateral pulmonary infiltrates that can be identified on chest radiography reflect the diffuse inflammatory changes within the lung that are caused by acute inflammation within the pulmonary tissue and the alveolar space. the initial inflammatory process is induced by the activation of the innate immune response by the binding of microbial products (pathogen-associated molecular patterns [pamps]) or cell injury-associated endogenous molecules (danger-associated molecular patterns [damps] ) to pattern recognition receptors (prrs). therefore, the common causes of ards are trauma, sepsis, pneumonia, blood transfusion, or aspiration into the lungs. after the initial activation of the innate immune response, innate immune effector mechanisms, such as the formation of neutrophil extracellular traps (nets), are activated, which further aggravate the alveolar injury [5] . the resulting increased permeability of the microvascular barrier results in the extravascular accumulation of protein-rich fluid that accumulates within the alveolar space. the increased permeability is also linked to the transfer of leukocytes (mostly neutrophil granulocytes) and erythrocytes into the alveolar space in ards, as well as to the presence of proinflammatory-regulated cytokines that increase the inflammatory burden within the lung [5] . as a result, dysregulated inflammation, the accumulation of leukocytes and platelets, and altered permeability of alveolar barriers remain the central pathophysiologic problems in ards [5, 6] . the treatment of ards to date is focused on the prevention of further iatrogenic damage of the lung through lung-protective mechanical ventilation, neuromuscular blockade, and conservative fluid management [7] . recent clinical trials have focused on the role of ventilation strategies in the prevention or treatment of ards using noninvasive ventilation devices or prone positioning [8, 9] . although these strategies have shown a positive effect on patient oxygenation and symptoms, they do not interfere with the underlying pathophysiological changes of ards. several interventions have tried to use a potential anti-inflammatory strategy for the treatment of the existing intra-alveolar inflammation or to intervene in the development of intra-alveolar inflammation. for this, patients were treated with aspirin, simvastatin, and surfactant, but the tested treatments failed and did not have any significant effect [10] [11] [12] . considerable evidence in preclinical models shows that the use of iloprost for the treatment of ards and pulmonary inflammation might be of significant benefit. in small animal models, investigators showed that iloprost improves endothelial barrier function and reduces the detrimental signs of pulmonary edema [13] . it also reduces the pulmonary sequestration of leukocytes and platelets, which is a central disease mechanism underlying the development of ards [14] . this evidence could be transferred into different models of lung injury, showing positive evidence for the reduction of pulmonary inflammation in a pressure-induced model of lung injury [15] . the anti-inflammatory effect was attributed to the cyclooxygenase-2 (cox-2) system and the involvement of lipoxin a4 [16] . ras-related protein 1 (rap-1) might also be involved in the protective role of iloprost [17] . this positive anti-inflammatory effect of iloprost on the pulmonary tissue was also demonstrated in several models of ischemia-reperfusion (ir) injury. furthermore, ir injury can also result in ards and pulmonary failure. iloprost was able to reduce this pulmonary compromise in several preclinical studies [18] [19] [20] [21] . the anti-inflammatory effect of iloprost was also shown in large animal models of lung injury using porcine models of ards [22] [23] [24] . here, again, iloprost showed an anti-inflammatory effect. in addition, the shunt fraction could be reduced, which resulted in improved oxygenation and improved pulmonary dynamics, which is essential for the reinstitution of spontaneous ventilation during and following ards [22, 23, [25] [26] [27] . this shows that the preclinical data identified a beneficial effect of iloprost on ards. so far, only one study on inhaled iloprost in adult patients with ards has been conducted, although an application of inhaled iloprost is noted in the guidelines of the association of the scientific medical societies (awmf) for the treatment of ards [28] . the awmf guidelines indicate that the use of ards can be considered, especially in patients with severe ards who are mechanically ventilated and not selfconsenting [7] . thilo is a multicenter, randomized, single blinded clinical phase ii trial assessing the efficacy of inhaled iloprost in the development and progression of ards in critically ill patients. based on the risk of pulmonary hemorrhage, which is very rare-especially in patients with ards-the study medication was unblended. for safety reasons, after treatment of 100 patients (day 28 after last dose investigational medicinal product [imp] patient 100) within the study, an interim analysis for an increased risk for pulmonary hemorrhage ≥ grade iii according to common terminology (toxicity) criteria for adverse events (ctcae) version 5.0 in the treatment (iloprost) arm will be performed and the results discussed with the data and safety monitoring board (dsmb). the study was ap the target population for this clinical trial is adult critically ill patients with ards. patients will be included in the trial if they present with ards as defined by the berlin definition (table 1 and [1] ) and meet the inclusion criteria. the trial population will consist of both sexes. one hundred fifty intensive care patients with ards will be included in the study at the department of anesthesiology, eberhard karls university tübingen, germany; the department of intensive care and intermediate care, university hospital rwth aachen, germany; and the department of anesthesiology, university hospital münster (ukm), münster, germany. patients meeting the following criteria will be included: age ≥ 18 years, pao 2 /fio 2 ≤ 300, bilateral infiltrates consistent with pulmonary edema on frontal chest radiograph, need for positive pressure ventilation via an endotracheal tube or noninvasive ventilation and no clinical signs of left atrial hypertension detected via echocardiography, or if measured, a pulmonary arterial wedge pressure (pawp) less than or equal to 18 mmhg. the term "acute onset" is defined as follows: the durations of the hypoxemia criterion and the chest radiograph criterion must be ≤48 h at the time of randomization. patients must be enrolled within 48 h of ards onset and no later than 7 days from the initiation of mechanical ventilation. the exclusion criteria are defined as follows: subject age < 18 years; time interval more than 7 days since the initiation of mechanical ventilation; more than 48 h since the onset of ards; patient, surrogate, or physician not committed to full intensive care support; positive pregnancy test at the time of screening; and contraindications against iloprost. these are defined as conditions in which the effects of iloprost on platelets might increase the risk of hemorrhage (e.g., active peptic ulcers, trauma, intracranial hemorrhage), severe coronary heart disease, myocardial infarction (within the last 6 months), decompensated heart failure, severe arrhythmias, unstable angina pectoris, pulmonary arterial hypertension caused by the occlusion of pulmonary veins, cerebrovascular events (e.g., transient ischemic attack, stroke) within the last 3 months, and congenital or acquired valvular defects with clinically relevant myocardial function disorders not related to pulmonary hypertension. patients who received iloprost treatment for any indication within 48 h prior to enrollment in the clinical trial or patients who were on thrombin inhibitors or nitric oxide (no) within the previous 24 h before study randomization were also excluded. additionally, patients dependent on the sponsor, investigator, or their employees were not included in the study. the imp is iloprost (ventavis®; drug code sub14185mig; atc code b01ac11), manufactured by berlimed s.a., madrid, spain (for bayer pharma ag, germany). it will be used as a concentrate for use in nebulizers and will be administered by inhalation three times a day (20 μg per administration). the administration of the drug will occur at the same time each day ± 1 h. in cases of severe adverse effects, the dosage will be reduced to 20 μg once a day (morning). other dose modifications or temporary cessation of the study drug will not be allowed. iloprost is usually dissolved in 0.9% sodium chloride (nacl), which is used to keep the ventilator circuit moist as standard of care. therefore, in the control group, nacl 0.9% will be used to keep the airway circuit moist, which is the standard of care for the treatment of patients with pulmonary insufficiency [7] . considering the pharmacokinetic and dynamic profile of iloprost, we have suggested an approach of an application of three times per day, with a dose of 20 μg, which seems to be an average dose in the trials reported up to now. the rationale behind this was that iloprost also exerts an antiinflammatory effect that may last up to 6 h [29] [30] [31] [32] [33] . therefore, an administration of iloprost three times a day would allow a significant time frame per day to be covered by anti-inflammation due to this drug. the duration of 5 days was included in the trial because the pathophysiology of ards develops within the first few days and is progressive during that period. randomization lists will be generated at the biostatistical center. based on these lists, numbered envelopes will be provided and used for randomization. relevant additional medications and treatments such as vasopressors, inotropes, anti-infective agents, inhalative therapy or sedation, steroids, and immunosuppressive therapy administered to the subjects on entry to the trial or at any time during the trial are regarded as concomitant medications and treatments and must be documented on the appropriate pages of the case report form (crf); these data will be grouped according to class of medication. depending on the substance, the documentation varies in details (e.g., dosing). this study will consist of the following consecutive phases: study entry, treatment, and follow-up. the time points and trial procedures are listed in table 2 . all patients included in this trial will receive standard care for ards according to the ards network, with special consideration of lung-protective ventilation strategies. in this trial, patients with ards present an emergency situation, such as the diagnosis of ards requiring intensive care unit (icu) admission and ventilation therapy, which does not allow for any delay of diagnostic workup or therapy. additionally, due to severe symptoms, the vast majority of patients who meet the eligibility criteria for the trial are assumed to be unable to give consent in the acute admission phase, and legally authorized representatives (lars) might not be available in most cases. this is also in line with local regulations: e.g., §41 of the german drug law allows the start of a treatment in an emergency situation without prior consent if the immediate treatment is necessary to save the patient's life, recover the patient's health, or ease the patient's suffering. in this situation the consent of an independent physician not directly involved in the study conduct will be sought before the beginning of any study-related activity. the consent has to be obtained as soon as the patient is able to give consent or a lar is available. independently, personal consent will be obtained from each patient after recovering consciousness and competence for decisionmaking or by a legal representative in cases recovering is not achieved during the study duration (i.e., day 27). when possible, however, the patient or his legal representative is to be informed both in writing and verbally by the investigator before any study-specific procedure is iloprost or nacl 0.9% (control) x x x x x clinical assessment including outcome x x x x x x x x x laboratory testing x x x x x x x x adverse/serious adverse event monitoring x x x x x x x plasma biomarkers x x x x x x barthel index x x x x sofa score x x x x x x x x health-related questionnaire x ves x performed. each patient or his legal representative will be informed about the modalities of the clinical study in accordance with the provided patient information. informed consent from the patient will be obtained using a form approved by the ethics committee (ec) of the universitätsklinikum tübingen or the local ec if the patient is treated in a collaborating institution. the treatment group will receive 20 μg of nebulized iloprost three times per day for 5 days in addition to standard care. iloprost will be measured in blood samples to determine the serum levels within this setting. the control group will receive nebulized 0.9% nacl with an equal volume three times per day for 5 days. after 5 days, the trial treatment will be complete (fig. 1) . blood samples will be drawn at defined time points for a variety of biomarkers to better assess the associations among coagulation, inflammation, and iloprost treatment. key cointerventions (infection control, aspiration precautions, fluids, and transfusion) will be standardized across all patients. mechanical ventilation will be standardized (see additional file 1). hospital survivors will undergo a brief follow-up phone survey to assess functional status (barthel index), a health-related questionnaire, and the vulnerable elders survey (ves) to assess frailty 6 months after enrollment. the patients will be visited daily until day 28 or until discharge from the icu, which could be beyond day 28. if discharged, the next visit will be on day 90; if patients are still in the icu, there will still be daily visits until this time point. data will be collected according to the study procedure until then. each visit will consist of a clinical examination, a blood sample, assessment of the functional capacity through the barthel index, and assessment of the severity of illness through the sequential organ failure assessment (sofa) score. all data will be recorded on an electronic case report form (ecrf); this will be used as a visit diary. blood samples will be drawn at defined visits for a variety of biomarkers to better assess the associations among coagulation, inflammation, and iloprost treatment (table 3) . the primary objective and endpoint is to assess the effect of iloprost on the improvement of oxygenation (pao 2 /fio 2 ratio) in patients with ards. as secondary objectives, the absolute incidence of the following parameters will be determined: fig. 1 trial protocol and intervention scheme. after screening and determination of eligibility, patients will be included after a maximum of 48 h after the onset of ards. within this time period, screening, consent, and randomization will be initialized. in addition, lung-protective ventilation will be instituted. after randomization, iloprost 3 × 20 μg (intervention) or nacl 0.9% (control) will be administered for 5 days through a standard ultrasound nebulizer. daily recordings will be made with respect to the development of the pao 2 /fio 2 ratio and the severity of ards, organ failure, lung injury, and potential adverse events. the treatment with iloprost or nacl (0.9%) will be stopped after 5 days. the follow-up period will then continue up to 90 days and 6 months to determine the outcome, quality of life, and pulmonary/secondary organ function overall survival in the 90-day follow-up period (90day all-cause mortality) duration of mechanical ventilation support icu length of stay ventilator-associated pneumonia pulmonary hemorrhage gastrointestinal hemorrhage pulmonary embolism hospital discharge or d90 laboratory testing blood count x a x a x a x a x a x a x b x c x x procalcitonin x a x a x a x a x a x a x b x c x x il-6 x a x a x a x a x a x a x b x c x x pao 2 /fio 2 x a x a x a x a x a x a x b x c hemoglobin x a x a x a x a x a x a x b x c x x hemostasis parameters x a x a x a x a x a x a x b x c x x renal parameters x a x a x a x a x a x a x b x c x x ventilation support including ventilation parameters x a x a x a x a x a x a x a prone positioning x a x a x a x a x a x a x a ecmo x a x a x a x a x a x a x a relaxation x a x a x a x a x a x a x a high-frequency ventilation x a x a x a x a x a x a x a tracheotomy hemodynamic parameters x a x a x a x a x a x a x b x x x vasopressor therapy x a x a x a x a x a x a x a inotrope therapy x a x a x a x a x a x a x a fluid balance x a x a x a x a x a x a x a transfusion of red blood cells x x x x x x x b x x x transfusion of thrombocytes x x x x x x x b x x x anticoagulation infection x x x x x x x b x x x anti-infective therapy x x x x x x x b x x x the exploratory objectives are 6-month survival, quality of life (qol) assessed with a short-form survey (sf12), functional status (barthel index), and frailty (ves) assessed by phone follow-up interview. the following parameters will be used to determine the treatment efficacy: improvement of oxygenation (pao 2 /fio 2 ) on a daily basis in relationship to baseline overall survival in the 90-day follow-up period decrease in duration and severity of ards sofa scores: to be calculated based on data in hospital records duration of mechanical ventilation support: documentation in hospital records icu length of stay: documentation in hospital records ventilator-associated pneumonia: documentation of microbiological findings in hospital records incidence of barotrauma: documentation of ventilator parameters in hospital records reduced morbidity assessed through sofa score, also according to the incidence of complications and increased functionality assessed through the barthel index delirium: documentation (e.g., confusion assessment method for the icu [cam-icu]) in hospital records icu-acquired weakness: documentation in hospital records discharge location: documentation in hospital records, phone call. the demographic parameters at enrollment include age, sex, race, icu admission diagnosis, and comorbidities (such as diabetes, existing malignancy, any kind of pre-existing pulmonary disease, and hypertension). the main clinical data obtained during the icu daily assessment are as follows: laboratory data: blood count, procalcitonin, interleukin (il)-6, creatinine, urea, partial thromboplastin time (ptt), d-dimers, international normalized ratio (inr), aspartate aminotransferase (ast), alanine aminotransferase (alt), albumin, cholinesterase (che), brain natriuretic peptide (bnp) weekly assessments of the icu will include the following: differential blood count creatinine clearance ecmo post-oxygenator pao 2 sofa score assessment at discharge chronic renal failure at discharge hepatic failure at discharge length of stay in the icu length of stay in the hospital discharge from hospital to a nursing home discharge from hospital to home discharge from hospital to a rehabilitation unit residence in nursing home at 6 months the final assessment will consist of the following: days of ecmo support ventilator days tracheotomy need for mechanical ventilation at home incidence of pulmonary hemorrhage defined by an indication for blood transfusion, radiological finding, or a decrease in oxygenation incidence of barotrauma incidence of pleural drainage incidence of pulmonary embolism defined by the following parameters: new hypotension sign of right ventricular failure on echocardiography biomarkers computed tomography (ct) scan (optional) incidence of gastrointestinal bleeding defined by the following parameters: upper gastrointestinal bleeding, blood vomiting, lower gastrointestinal bleeding, melena, indication for blood transfusion, endoscopic diagnosis/intervention incidence of cerebral hemorrhage defined by the following parameters: impairment as measured by the glasgow coma scale, ct scan infections: incidence of positive blood culture, pneumonia, wound infection, peritonitis, surgical intervention due to infection, bacterial infection, fungal infection, viral infection, or multidrugresistant gram-negative bacteria (mrgn) infection anti-infective therapy: generic, duration, incidence of changing anti-infective therapy due to inadequate treatment incidence of surgical intervention. the trial case report form (crf) is the primary data collection instrument for the trial. for this project, electronic crfs (ecrfs) will be used. entered data will be subjected to plausibility checks directly implemented in the crf, monitoring, and medical review. the trial master file, the crfs, and other material supplied for the conduct of the study will be retained by the sponsor/ clinical research organization (cro) according to applicable regulations and laws. the investigator(s) will archive all trial data (source data and investigator site file [isf], including the subject identification list and relevant correspondence) according to the international conference on harmonization of technical requirements for registration of pharmaceuticals for human use (ich) consolidated guideline on good clinical practice (gcp) and local laws or regulations. the study population will consist of the following: those to be assessed for eligibility (n = 300); those to be assigned to the trial (n = 150); those to be analyzed (n = 150 in the intention-to-treat [itt] analysis, other endpoints n = 120). the sample size and power consideration refers to 120 evaluable patients, and it is assumed that the power will not be decreased in the analysis of the itt population using multiple imputation. furthermore, baseline adjustment will not be taken into account, which leads to a conservative sample size estimation. in a previous study on iloprost with 20 patients, an increase from 177 ± 60 to 213 ± 67 was observed for the pao 2 /fio 2 , which was significant at the 0.01 level [27] . recalculation shows that the intraindividual standard deviation must have been considerably smaller, as a p value of 0.01 corresponds to an effect size of 0.93 (intraindividually) and thus to an intraindividual standard deviation of approximately 40 in this study. in our study, we can show effect sizes of 0.525 assuming 116 error degrees of freedom, taking into account 1 day for baseline adjustment and 3 days for the study center (inquiry, power 80%, level of significance 0.05, twosided t test). if we assume the recalculated standard deviation from the previous study in our study (which is still conservative due to the linear baseline adjustment used in our study), an (interindividual) effect size of 0.525 corresponds to a difference of approximately 21 in the pao 2 /fio 2 ratio in the treatment arm compared to the control arm. this seems to be a reasonable and relevant effect. the primary endpoint of pao 2 /fio 2 at day 6 after the baseline will be analyzed daily using a baseline adjusted analysis of covariance model with the last measurement of the pao 2 /fio 2 ratio before treatment as the baseline, with the study arm as a second-level factor. the study center will be included in the analysis as a nuisance factor. additionally, an interaction term between baseline and treatment will be included in the model if this term is significant. in the case of interaction, the main effect will be retrieved for the arithmetic mean of the baseline values using the centered variable for pao 2 /fio 2 . multiple imputation will be applied in the itt population of patients receiving at least one dose of treatment or the control. statistical analysis of the prespecified secondary endpoints will be performed with descriptive and exploratory statistical methods according to the scale and observed distribution (absolute and percentage frequencies, chi-square tests, logistic regression models for categorical variables; means and standard deviations, medians, and quartiles, or ranges with t tests or mann-whitney tests and linear regression models for continuous variables; kaplan-meier curves, log-rank tests, and cox proportional hazard models for censored data). the p values will be reported but should not be considered part of the confirmatory analysis. planned subgroup analyses will be performed according to the following: sex and race (only for subgroups larger than 40 subjects) patients with increased pulmonary arterial pressure direct vs. indirect lung injury age stratified by decades. for safety reasons, after the enrollment of 20 patients (day 28 after last dose imp patient 20), an interim analysis of the following will be performed: 1. an increased risk of pulmonary hemorrhage ≥ grade iii according to ctcae version 5.0 in the treatment (iloprost) arm 2. levels of imp in the serum. the results will be discussed with the dsmb. the dsmb has to assess whether the results allow continuation of the study as planned. moreover, after treatment of a total of 100 patients (day 28 after the last dose imp patient 100), an interim analysis of an increased risk of pulmonary hemorrhage ≥ grade iii according to ctcae version 5.0 in the treatment (iloprost) arm will be performed, and the results will again be discussed with the dsmb. the dsmb must assess whether the results allow continuation of the study as planned. moreover, in the following situations, a premature termination of the trial must be considered: 3. substantial changes in risk-benefit considerations 4. new insights from other trials 5. insufficient recruitment rate. the biometric report will be delivered according to the sop bi07 of the statistical center (ikeab). in summary, the report will contain sections on the statistical methodology, preprocessing of data, and the descriptive, exploratory, and confirmatory analyses. it will be reviewed by the principal investigator (pi) before presenting the final version. to date, there is no pharmacologic intervention to treat or prevent the development of lung injury or ards. iloprost-containing medications are well recognized epidemiologically as an effective therapeutic agent for the treatment of moderate to severe pulmonary hypertension. iloprost has been shown to exert antiplatelet and anti-inflammatory actions in small clinical observation studies and several preclinical laboratory examinations. however, the use of iloprost for the treatment of ards is not novel; it has been used in small studies before. indeed, we propose in this study to systemically evaluate the application of iloprost in a randomized controlled trial (rct) to identify the potential use and benefit of iloprost in ards. the composite endpoint was chosen, as it is likely to be more sensitive than just 28-day mortality to detect an effect signal. although it is not a double-blinded strategy, the recorded objectives will help support or refute our hypothesis that iloprost reduces lung inflammation during early ards. this study includes some possible pitfalls, like the single-blinded design. however, due to randomization and based on the close data acquisition, we will be able to minimize bias. however, in addition to the effect of iloprost on lung inflammation, this study will also be a resource for information about clotting issues in terms of the systemic and local anticoagulation effects of iloprost in lung tissue, and also in other compartments besides the lung. although iloprost is used frequently in pulmonary hypertension, there are currently no data about iloprost concentration in the blood after inhalative treatment. in addition, iloprost may have a positive effect on lung compliance during acute ards as well as during resolution, since it has been shown to have a lasting positive effect on fibrosis in the lung and other tissues in animal models [34, 35] . in one-lung ventilation, iloprost seems to reduce intrapulmonary shunts, resulting in better oxygenation [36, 37] . in this context, the analysis of ventilator-free days or time on ecmo may reveal important information. further on, intravenous application of iloprost may improve microcirculation, resulting in better kidney recovery in patients with sepsis [37, 38] . patients with ards frequently show multiorgan failure. therefore, the comparison of incidence and time frame for extracorporeal therapy may give insights on the effect of inhaled iloprost on microcirculation in other organs. therefore, iloprost may positively influence the outcome of ards patients by at least one of the effects described above. this study will be the first to describe the effects of iloprost on inflammation, fibrosis, bleeding events, and oxygenation organ failure and anticoagulation during a continuous time frame of at least 5 days in critically ill patients. the berlin definition of ards: an expanded rationale, justification, and supplementary material the american-european consensus conference on ards. definitions, mechanisms, relevant outcomes, and clinical trial coordination long-term outcomes after ards long-term assessment of lung function in survivors of severe ards the acute respiratory distress syndrome the acute respiratory distress syndrome leitlinie invasive beatmung und einsatz extrakorporaler verfahren bei akuter respiratorischer insuffizienz effect of noninvasive ventilation delivered by helmet vs face mask on the rate of 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hypertension as a bridge to heart transplantation iloprost improves gas exchange in patients with pulmonary hypertension and ards aerosolized prostacyclins for acute respiratory distress syndrome (ards) the effects of iloprost and alprostadil on ischemia-reperfusion injury in preventing inflammation, tissue degeneration, and apoptosis in rat skeletal muscle increased neutrophil mediator release in patients with pulmonary hypertension-suppression by inhaled iloprost assessment of the vasodilator response in primary pulmonary hypertension. comparing prostacyclin and iloprost administered by either infusion or inhalation pharmacokinetics and pharmacodynamics of the prostacyclin analogue iloprost in man effects of hyperbaric oxygen and iloprost on intestinal ischemia-reperfusion induced acute lung injury iloprost reverses established fibrosis in experimental right ventricular failure effects of iloprost on bleomycin-induced pulmonary fibrosis in rats compared with methyl-prednisolone the effects of iloprost on oxygenation during one-lung ventilation for lung surgery: a randomized controlled trial iloprost preserves renal oxygenation and restores kidney function in endotoxemia-related acute renal failure in the rat intravenous iloprost to recruit the microcirculation in septic shock patients? publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-4163-0. authors' contributions pr and hah drafted the current manuscript. mg, az, mk, pm, and sp critically reviewed and revised the draft report. all authors have read and approved the final version, which was also approved by the sponsor. this study is financed by the akf (applied clinical research) program (414-0-0) for the faculty of medicine of the university of tübingen. the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. the thilo trial protocol was approved by the ethics committee of the university of tübingen, germany (protocol number 899/2018amg1) on 4 june 2019. the local ethics committee at each site will approve the study protocol (approvals already in place are shown in additional file 2). any modifications to the protocol will be immediately communicated to all responsible authorities. all patients, or their legal representative, must give written informed consent. not applicable. the authors declare that they have no competing interests. key: cord-334956-pi8ifpcy authors: chan, raymond javan; emery, jon; cuff, katharine; teleni, laisa; simonsen, camilla; turner, jane; janda, monika; mckavanagh, daniel; jones, lee; mckinnell, emma; gosper, melissa; ryan, juanita; joseph, ria; crowe, bethany; harvey, jennifer; ryan, marissa; carrington, christine; nund, rebecca; crichton, megan; mcphail, steven title: implementing a nurse-enabled, integrated, shared-care model involving specialists and general practitioners in breast cancer post-treatment follow-up: a study protocol for a phase ii randomised controlled trial (the eminent trial) date: 2020-10-15 journal: trials doi: 10.1186/s13063-020-04740-1 sha: doc_id: 334956 cord_uid: pi8ifpcy background: due to advances in early detection and cancer treatment, 5-year relative survival rates for early breast cancer surpass 90% in developed nations. there is increasing focus on promotion of wellness in survivorship and active approaches to reducing morbidity related to treatment; however, current models of follow-up care are heavily reliant on hospital-based specialist-led care. this study aims to test the feasibility of the eminent intervention for implementing an integrated, shared-care model involving both cancer centre specialists and community-based general practitioners for early breast cancer post-treatment follow-up. methods: we describe a protocol for a phase ii, randomised controlled trial with two parallel arms and 1:1 allocation. a total of 60 patients with early-stage breast cancer will be randomised to usual, specialist-led, follow-up care (as determined by the treating surgeons, medical oncologists, and radiation oncologists) or shared follow-up care intervention (i.e. eminent). eminent is a nurse-enabled, pre-specified shared-care pathway with follow-up responsibilities divided between cancer centre specialists (i.e. surgeons and oncologists) and general practitioners. the primary outcome is health-related quality of life as measured by the functional assessment of cancer therapy—breast cancer. secondary outcomes include patient experience, acceptance, and satisfaction of care; dietary, physical activity, and sedentary behaviours; financial toxicity; adherence; health resource utilisation; and adverse events. discussion: the trial is designed to identify the barriers to implementing a shared-care model for breast cancer survivors following treatment. results of this study will inform a definitive trial testing the effects of shared-care model on health-related quality of life of breast cancer survivors, as well as its ability to alleviate the growing demands on the healthcare system. trial registration: australia and new zealand clinical trials registry actrn12619001594112. registered on 19 november 2019 discussion: the trial is designed to identify the barriers to implementing a shared-care model for breast cancer survivors following treatment. results of this study will inform a definitive trial testing the effects of shared-care model on health-related quality of life of breast cancer survivors, as well as its ability to alleviate the growing demands on the healthcare system. the order of the items has been modified to group similar items (see http://www.equator-network.org/reporting-guidelines/spirit-2013-statement-defining-standardprotocol-items-for-clinical-trials/). in australia, breast cancer is the most common cancer in females with an estimated 19,535 new cases annually [1] . with advances in early detection and cancer treatment, such as surgery, post-operative radiotherapy, and pre-or post-operative systemic therapies including cytotoxic chemo-, endocrine, and anti-her2 antibody therapies, the 5-year relative survival rate for breast cancer is estimated at 91% [2, 3] . consequently, in 2018, there were at least 200,000 breast cancer survivors living in australia [4] . despite good survival outcomes, breast cancer survivors require supportive care including prevention of cancer recurrence, surveillance for secondary or new primary cancer, and management of a range of long-term bio-psycho-social effects from their cancer diagnosis and treatment. in addition, many cancer survivors need management of comorbidities as they are 2.5 times more likely to develop mental and behavioural problems and almost 1.5 times more likely to develop musculoskeletal conditions, circulatory conditions, and endocrine system disorders compared with non-cancer patients [5] . these health concerns highlight the importance of a comprehensive, well-integrated, patient-centred model of care for people following completion of breast cancer treatment. the current models of post-treatment care in australia are mostly hospital-based and specialist-driven and focus on surveillance for disease recurrence, rather than the holistic care needs of cancer patients. this model of followup care limits the integration between specialist institutions and general practitioners (gps), overloads the specialist system, and is unsustainable to meet the demands of the ever-growing population of cancer survivors. specialist-based follow-up carries the burdens of travel and out-of-pocket costs such as those for parking. those in non-metropolitan areas face more major disruptions to engage in specialist-based follow-up. therefore, there is a strong case for an integrated, shared post-treatment follow-up care model for breast cancer survivors that involves both cancer specialists as well as care provided in the community by gps. such a shared-care model is consistent with cancer australia statements [6] , the optimal care pathway for breast cancer [7] , and international guidelines [8] . in addition, the literature suggests that such a model is feasible, acceptable, safe, and more cost effective and patient-centred than current models used within australia [9, 10] . despite the promising evidence base, a shared followup care model in which specialists in the acute cancer care setting and gps collaborate is not routinely implemented across australia and many developed nations. barriers to such shared care include the lack of a coordination between multiple providers, lack of patient and provider knowledge about the benefits of shared care and how to implement it, insufficient or delayed communication between cancer specialists and gps, and lack of awareness of available support such as funding models, tools, and resources [11, 12] . these barriers could be overcome if a specialist cancer nurse advises stakeholders (patient and gps) of the benefits of sharedcare, facilitates effective and timely care coordination, and acts as the conduit between the specialist cancer multidisciplinary team and the gps at key transition time points, such as completion of definitive primary and adjuvant treatment [13] . the objective of the study is to test the feasibility of a prospective, pragmatic randomised controlled trial (rct) of the eminent intervention-a nurse-enabled, integrated, shared-care model involving cancer specialists and gps for early breast cancer post-treatment follow-up. this phase ii pilot rct aims to assess the feasibility of a larger definitive clinical trial. outcome data will be collected at four timepoints (or five if booster nurse clinic is attended): (t 1 ) baseline (at enrolment ± prior to booster nurse clinic, if relevant), (t 2 ) 3 months, (t 3 ) 6 months, and (t 4 ) 12 months. this study is conducted in a large, australian metropolitan tertiary teaching hospital and general practices. the study population consists of patients with earlystage breast cancer (i.e. no-distant metastases) or ductal carcinoma in situ (dcis). patients will be eligible to participate from 2 weeks prior to completion of definitive treatment (surgery or adjuvant chemotherapy) and up to 18 months after completion of treatment. patients meeting all of the following criteria are eligible for inclusion: diagnosis of curable, early breast cancer; receiving care at the princess alexandra hospital; able to speak and read english; 18 years of age or older; ambulatory at the time of recruitment; eastern cooperative oncology group (ecog) performance status 0 or 1; able to nominate a gp or gp clinic to be involved in their follow-up; and access to a telephone. patients meeting any of the following criteria are excluded: presence of severe mental, cognitive, or physical conditions that would limit the patient's ability to provide informed consent. potential participants are identified by the research nurse or treating clinician during multidisciplinary team meetings. participants are approached by their treating clinicians to gauge their interest in the study and gain verbal consent to being approached by the research team. participants are then contacted by the research nurse, screened for eligibility, and provided with study information, and after a time of reflection (at least 24 h), they sign the consent form with the research nurse. table 3 outlines the different phases of the study and data collection. consent to access medicare and pharmaceutical benefits scheme (pbs) data on service use that qualifies under the medicare benefits schedule (mbs) will be obtained, including relevant claims details (date of service, medicare item number, and description) and costs details. survivorship care of breast cancer survivors following completion of treatment is an important issue, especially in light of improving survival rates [2] . the shared-care model between specialists and gps focusses on the complex care needs of breast cancer survivors, rather than solely on disease recurrence, and may influence patient health outcomes and service outcomes [10] . arm 1 the control group will receive usual follow-up care supplemented with a survivorship booklet on living well after cancer published by cancer council australia [14] . the usual care follow-up arrangement is a specialist-led model as determined by the treating surgeon, medical oncologist, and radiation oncologist. this specialist-led follow-up care is not standardised and with follow-up activities and schedules depending on individual patient needs and the discretion of the treating clinicians. eminent is a multi-faceted intervention that includes a pre-specified shared-care pathway for post-treatment follow-up. the design of the eminent intervention is informed by a number of cancer australia statements, the optimal care pathway [15] , the self-efficacy model [16, 17] , the capabilities for supporting prevention and chronic condition self-management framework [18] , and our extensive pilot work including a systematic review [19] and observational studies [20] [21] [22] [23] . table 1 outlines the active ingredients of the eminent intervention. after enrolment, participants who have completed chemotherapy and radiotherapy or those who will receive aromatase inhibitor will participate in a 20-min telehealth cancer pharmacist consultation for medication reconciliation and education prior to specialist nurse consultation. a 30-60-min consultation with a specialist cancer nurse is then conducted to provide a treatment summary, the shared follow-up care appointment schedule, and survivorship patient education (including the survivorship booklet on living well after cancer published by cancer council australia [14] ) and to codevelop a draft survivorship care plan (scp). the scp includes up to three smart (specific, measurable, achievable, realistic, and timely) goals that are developed by the nurse and patient in partnership using motivational interviewing and self-efficacy techniques. due to the recent covid-19 pandemic, where there are delays of 3-18 months before gp involvement, a second 'booster' specialist cancer nurse consultation is offered to patients to update the scp. the treatment summary and draft scp is provided to the gp. within 4 weeks of the specialist cancer nurse consultation, a 5-30-min case conference between the specialist cancer nurse and the patient's nominated gp is completed to communicate the treatment summary and shared follow-up care schedule and to finalise the scp and negotiate the gp's role in facilitating the scp goals. the gp may propose changes or express if they are not willing to take part in specific care activities outlined in the scp. the finalised scp is then filed in the patient's medical records and provided to the patient and the gp. the shared, follow-up care schedule consists of 6monthly patient appointments with a cancer centre specialist and annual appointments with the gp for 2 years post-diagnosis. following this, the schedule consists of alternating 6 monthly appointments with a cancer centre specialist and gp for up to 5 years post-diagnosis. at 5 years post-diagnosis, patients are discharged to the care of the gp, as per usual care. the gp appointments will focus on reviewing the scp; promoting general health; primary prevention, screening, and management of comorbidities; psychosocial health; cancer treatment toxicities; cancer-related symptoms; chronic disease management planning; and allied health referrals. the gp has direct telephone access to the specialist cancer nurse in case of concerns or escalation for acute care review. the cancer centre specialist appointments focus on surveillance activities such as physical examination and imaging (i.e. annual mammogram). the presence of any of the following criteria constitutes cause for the withdrawal of the participant: altered mental capacity resulting in inability to provide continuing informed consent, notification from treating oncologist and/or gp that the participant is not deemed to have the capacity to consent, and recurrence or progressive disease or death. fidelity of the intervention will be assessed using the framework for behavioural interventions recommended by the national institute of health (nih) [24, 25] as outlined in table 2 . no concomitant care or intervention is prohibited during the trial. there is no ancillary or post-trial care for participants in this trial. however, it is expected that the scp generated will have the value of informing longer term updates of the scp and future survivorship care. the feasibility outcomes are recruitment and acceptability of the intervention. the primary endpoint is healthrelated quality of life (hrqol) as measured by functional assessment of cancer therapy-breast cancer (fact-b) [26] at baseline, 3, 6, and 12 months post-enrollment. the 37-item fact-b is a valid and reliable tool for use in cancer survivors undergoing as well as beyond treatment and has been demonstrated to be sensitive to changes over time [27] . a total score as well as scores for each of the five subscales (physical, social/family, emotional, functional wellbeing, additional breast cancer concerns) are calculated, where higher scores indicate higher quality of life. fact-b captures key domains of hrqol and key symptoms that are relevant to the study population and sensitive to the eminent intervention. additional outcomes include a range of patientreported secondary endpoints, and process outcomes related to implementation as shown in table 3 . participants of the intervention group, as well as their nominated carer, breast cancer nurses, gps, and other healthcare providers including other nurses, and hospital-and community-based rehabilitation providers will be invited to participate in a semi-structured interview. open ended questions (online supplementary material 1) will explore key factors that facilitate or hinder the implementation of the eminent intervention. in this pilot study, we will recruit 30 patients per arm in order to provide initial insights into the intervention feasibility and protocol as well as preliminary effect size estimates. the aim of this study is not hypothesis testing, and the power level is therefore not a valid consideration for sample size [28, 29] . the sample size for this study (n = 60) falls within the range of sample size recommendations for pilot studies of this nature [28, 29] . participants are recruited through the hospital cancer outpatient clinics and therapy units. research nurses and designated health professionals identify potential participants. potential participants are reviewed by a member of the treating team and asked if they would like to be approached by a research nurse or designated table 2 intervention fidelity strategies (adapted) training providers specialist cancer nurses will be trained to standardise the delivery of the intervention to study participants. training includes provision of study manual containing • generic study information: standard operating procedures, study overview, reporting and documentation guidelines, communication flowchart, rationale for the study treatment, completion of survivorship care plan, self-management goal setting, and health coaching • specialist cancer nurse-specific information: job description, intervention protocol, quality assurance, and monitoring an 8-h training program will be delivered by experts in cancer survivorship and motivational interviewing. the program includes the national cancer nursing education (edcan) learning module on survivorship, related literature, didactic presentations, and roleplay covering: basic concepts of quality cancer survivorship care, components of a high-quality treatment summary and survivorship care plan; provision of self-management support (including collaborative goal setting; motivational interviewing); and mbs item numbers that facilitate the proposed model of care. intervention procedures are monitored through completion of intervention component checklists to ensure that the intervention is delivered as intended. intervention checklists are completed during clinics and gp case conferences to track protocol deviations across specialist cancer nurses and study arms. the intervention fidelity is closely monitored and discussed during the weekly 30-min meeting for the first 3 months of the trial between the specialist cancer nurses, research nurses, and investigators. minimising contamination between conditions by training interventionists to address participant questions about randomisation and their assigned condition using non-biased explanations. the scp serves as a resource for a participant to understand and refer to whenever they are unsure of follow-up schedule and collaborative goal setting. enactment of treatment skills enactment of treatment skills includes processes to monitor and improve participant ability to perform treatmentrelated behavioural skills and cognitive strategies in relevant real-life settings as intended. this goal will be achieved by ensuring participants are aware of the follow-up schedules and responsibilities of all health professionals, ensuring participants will have a copy of the completed scp including all care responsibilities and goals set for the individual, and checking in with participants once in the first week into the model, then monthly/bimonthly until the end of the trial period as resources allow. health professionals for consent to participate in the study. participants are given as much time as possible to consider their participation and are encouraged to take the information away and discuss participation in the trial with family, friends, and their gp if they so wish to. participants are also encouraged to ask the research nurses, their treating doctors, or nursing staff any questions in relation to their participation. computer-generated random numbers are used to allocate participants in a 1:1 ratio by a researcher not involved in recruitment, intervention implementation, or data collection. randomisation is blocked using random permuted blocks of eight and four to ensure that the groups are balanced periodically within stratification groups. stratification groups include patients who have received (1) surgery only, (2) surgery and radiation only, (3) surgery and chemotherapy ± radiation and are her2 negative, and (4) surgery and chemotherapy ± radiation and are her2 positive. these stratification groups were chosen, with clinician input, to allow learnings for patients with different treatment pathways with different follow-up needs to inform the future definitive trial. allocation sequence is implemented using sequentially numbered opaque, sealed envelopes. envelopes are only accessed by the research nurse to randomise the patient once recruitment and baseline data has been collected. eligibility screen x informed consent x allocation x health-related quality of life x x x x allocation sequence is generated by a researcher not involved in recruitment or data collection. patients are enrolled by a research nurse who collects baseline data prior to randomisation. enrolling nurses assign participants to the intervention after baseline data collection. who will be blinded {17a} after assignment to the intervention, only outcome assessors are blinded to group allocation. where participants opt to complete their data collection by phone, they are advised not to reveal their group allocation to the outcome assessor. due to the nature of the intervention, no participants or treating clinicians are blinded. no unblinding procedures required as only outcome assessors and data analysts are blinded. plans for assessment and collection of outcomes {18a} patient-reported outcomes are self-administered using online surveys or administered in person or via telephone with an outcome assessor trained in the administration of the study instruments. the description of study instruments is listed in table 3 . the primary outcome is hrqol as measured by functional assessment of cancer therapy-breast cancer (fact-b) [26] . this validated and reliable instrument is well-used in cancer survivors undergoing and beyond treatment [27] , and it captures key domains of hrqol and key symptoms that are relevant to the eminent intervention. the secondary outcomes are listed below: patient experience of care as measured by the picker patient experience 15 (ppe-15) questionnaire [30] . the ppe-15 highlights aspects of care that need improvement to monitor performance and care. it consists of 15 questions distributed to seven dimensions of care: respect, coordination, information/communication/education, physical comfort, emotional support, involvement of relatives, and transitions to community [31] . dietary behaviours, specifically usual vegetable intake and usual fruit intake, as measured by two short dietary questions from the national nutrition survey [32] , which have been validated in the australian population. both questions discriminate between groups with significantly different fruit and vegetable intakes. in administering these questions, information about which foods are included as vegetables and fruits is provided and serve sizes are described. physical activity as measured by the active australia survey [33] which is designed to measure participation in leisure-time physical activity, and a single item from the international physical activity questionnaire [34] will be used to measure sedentary behaviours. financial toxicity as measured by the 11-item comprehensive score for financial toxicity (cost)-functional assessment of chronic illness therapy (facit) tool [35] . this tool is valid and reliable in measuring financial toxicity in patients with cancer [36] . adherence to clinical assessments including annual mammography, annual physical examination, and endocrine therapy as measured by hospital records. emergency presentations and hospitalizations as recorded from hospital records. satisfaction of care as measured by a 0-10 numerical analogue scale with 0 being the least satisfied and 10 being the most satisfied, supplemented with short, structured qualitative questions. process outcomes, including completion of intervention components, as measured by completion of intervention materials such as scps and checklists, number and length of clinical encounters recorded from mbs data and hospital records, and barriers and facilitators to implementation as explored through semi-structured interviews with patient participants, their nominated carer, breast cancer nurses, gps, and other healthcare providers including other nurses, and hospital-and community-based rehabilitation providers. health resource utilisation assessing both health service use and participant out-of-pocket costs including mbs and pbs administrative data sets. these data inform participants' utilisation of services that qualify under the mbs as well as medications dispensed under the pbs. it is planned that the economic evaluation may be reported separately from the main trial. participants who deviate from the protocol are not withdrawn from the trial. participants who withdraw from the trial nominate the degree to which they withdraw (i.e. whether they withdraw from active data collection ± passive data collection such as mbs/pbs data). all participant characteristic and outcome data are entered directly into redcap (research electronic data capture -vanderbilt university, hosted at queensland university of technology) by the research nurse ± the participants through self-administered online survey. to ensure data quality, the database is designed with branching logic, data validation, and range checks for data values, where possible. all source data, clinical records, and laboratory data relating to the study will be archived at the clinical site as appropriate for 15 years after the completion of the study. all data will be available for retrospective review or audit. no study document will be destroyed without prior written agreement between the responsible organisation and the investigator. if the investigator wishes to assign the study records to another party or move them to another location, he/she must notify the responsible organisation in writing of the new responsible person and/ or the new location. data on potential participants is recorded, including reasons for ineligibility or refusal to participate. participants are only identified by a unique participant study number on the case report forms and other study documents. other study-related documents (e.g. signed consent form, participant log) are kept in strict confidence by the investigator. participants are informed that data is held on file by the responsible organisations and that these data may be viewed by staff including the study project manager and by external auditors on behalf of the responsible organisations and appropriate regulatory authorities (to include reviewing human research ethics committee (hrec) and the research governance officers). participants will be identified in publication and conference presentation reports only in aggregated form. all participant data will be held in strict confidence. plans for collection, laboratory evaluation, and storage of biological specimens for genetic or molecular analysis in this trial/future use {33} not applicable. there is no collection of biological specimens in the current trial. descriptive statistics will be used to report on feasibility and process-related elements (e.g. recruitment, intervention, retention rates) as well as clinical and resource outcomes. preliminary effect size estimates for patient and resource use outcomes will be calculated following intention-to-treat principles using generalised linear mixed models. the distribution of the mixed models will be chosen as appropriate for the data, for example, a linear model for scale data or a poisson for count data. models will be adjusted for variables used in stratification of the randomisation process. residuals of all models will be examined for statistical assumptions using descriptive statistics and plots. not applicable. no interim analysis is planned. all qualitative interviews with participants assigned to the eminent intervention are audio-recorded and transcribed verbatim for analysis guided by the consolidated framework for implementation research [24] . methods in analysis to handle protocol non-adherence and any statistical methods to handle missing data {20c} preliminary effect size estimates for patient and resource use outcomes will be calculated following intention-totreat principles using generalised linear mixed models. patterns of missing data will be examined using chisquare and t tests. missing data for the outcomes will be accounted for by using mixed models allowing the use of each available case by computing maximum likelihood estimates. plans to give access to the full protocol, participant leveldata, and statistical code {31c} not applicable. there are no plans for granting public access of the full protocol, participant-level dataset, or statistical code. composition of the coordinating centre and trial steering committee {5d} the chief investigators are the trial steering committee that will provide all governance to the conduct of the study. composition of the data monitoring committee, its role, and reporting structure {21a} not applicable. there is no data monitoring committee established for this pilot trial. an adverse event (ae) is any event, side effect, or other untoward medical occurrences that occur in conjunction with the use of the study intervention in humans, whether or not considered to have a causal relationship to the interventions. an ae can, therefore, be any unfavourable and unintended sign (that could include a clinically significant abnormal laboratory finding), symptom, or disease temporally associated with the use of the study intervention, whether or not considered related to the intervention. conditions recognised as being excluded from ae reporting are as follows: any event, side effect, or other medical occurrences that are anticipated because of the normal course of treatment (standard care). there are no known side effects/adverse events associated with the proposed model of care intervention [9] . due to the nature of this intervention, there will be no reporting of ae. there are no plans for auditing trial conduct beyond the independent research governance requirements and annual reporting to the hrec. plans for communicating important protocol amendments to relevant parties (e.g. trial participants, ethical committees) {25} all agreed protocol amendments are clearly recorded on a protocol amendment form and are signed and dated by the original protocol approving signatories. all protocol amendments will be submitted to the institutional hrec for approval before implementation. the only exception will be when the amendment is necessary to eliminate an immediate hazard to the trial participants. in this case, the necessary action will be taken first, with the relevant protocol amendment following shortly thereafter. once hrec approval has been granted, investigators and the anzctr will be updated. it is intended that the findings from this trial will be disseminated at academic and professional conferences and via a manuscript submission to a peer-reviewed journal. participants will be identified in such reports only in aggregate or by study identification number, gender, and age. there are no publication restrictions. despite the strong case for a shared, follow-up care model for breast cancer survivors involving cancer specialists and gps, barriers to shared care mean that it is not routinely implemented across australia. these include the need for coordination across multiple providers, the need for improved patient and provider knowledge about the benefits of shared care and how to implement it, insufficient or delayed communication between cancer specialists and gps, and lack of awareness of available support such as funding models, tools, and resources [11, 12] . the current study aims to address these barriers using a specialist cancer nurse to advise stakeholders of the benefits of shared care (patient and gps), facilitate effective and timely care coordination, and act as the conduit between the specialist cancer multidisciplinary team and the gps. practical issues for this trial include estimating the time required to coordinate the trial across multiple providers including engaging gps and fidelity with the intervention components. the proposed study will provide important information on the feasibility of a definitive phase 3 trial for implementing a nurseenabled, integrated, shared-care model involving cancer specialists and gps for early breast cancer posttreatment follow-up. the information collected through the trial, qualitative interviews, and economic evaluations are crucial in guiding the development of such a trial. the protocol published here is version 2.0 dated 24 march 2020. the trial began recruitment on 3 december 2019 and is expected to continue until 20 november 2021. trial registration: australia and new zealand clinical trials registry, actrn12619001594112. registered on 19 november 2019, https://www.anzctr.org.au/trial/ registration/trialreview.aspx?id=378690&isreview=true. responsible for delivering the pharmacist consult. all authors have provided input and have read and approved the final manuscript. this study is funded by 2019 metro south health research support scheme project grant (funded by the metro south study, education and research trust account (serta)). the funding body had no role in the design of the study and will not have a role in the collection, analysis, and interpretation of data or in writing the manuscript. there are no limitations on investigator access to the trial dataset. the datasets generated and/or analysed during the current study are not going to be made publicly available but will be made available from the corresponding author on reasonable request. this study is approved by the metro south hospital and health services human research ethics committee (hrec/2019/qms/51956). written informed consent will be obtained from all participants. not applicable. no details, images, or videos relating to an individual person will be published, as all data will be presented in aggregate. australian institute of health and welfare. cancer data in australia. canberra: aihw australian institute of health and welfare australian institute of health and welfare. breastscreen australia monitoring report 2014-15 australian institute of health and welfare. cancer compendium: information and trends by cancer type comorbidity, physical and mental health among cancer patients and survivors: an australian population-based study cancer australia statement -influencing best practice in breast cancer. surry hills: cancer australia victorian department of health and human services of clinical oncology breast cancer survivorship care guideline randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care a new model supporting best practice follow-up care for early breast cancer in australia: shared follow-up care for early breast cancer adult cancer survivors discuss follow-up in primary care: 'not what i want, but maybe what i need oncologists' perceived barriers to an expanded role for primary care in breast cancer survivorship care cancer nurses can bridge the gap between the 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needs, quality-of-life perceptions and current symptoms in cancer survivors across the asia-pacific region: results from the international step study provision of survivorship care for patients with haematological malignancy at completion of treatment: a cancer nursing practice survey study enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the nih behavior change consortium ensuring treatment fidelity in a multi-site behavioral intervention study: implementing nih behavior change consortium recommendations in the smart trial reliability and validity of the functional assessment of cancer therapy-breast qualityof-life instrument a systematic review of quality of life instruments in long-term breast cancer survivors considerations in determining sample size for pilot studies sample size of 12 per group rule of thumb for pilot study the picker patient experience questionnaire: development and validation using data from in-patient surveys in five countries properties of the picker patient experience questionnaire in a randomized controlled trial of long versus short form survey instruments evaluation of short dietary questions from the 1995 national nutrition survey. canberra: australian government department of health and ageing australian institute of health and welfare. the active australia survey: a guide and manual for implementation, analysis and reporting international physical activity questionnaire: 12-country reliability and validity the development of a financial toxicity patient-reported outcome in cancer: the cost measure measuring financial toxicity as a clinically relevant patient-reported outcome: the validation of the comprehensive score for financial toxicity (cost) publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors acknowledge the contribution of drs kathryn middleton, wen xu, kate roberts, vladimir andelkovic, margo lehman, and tao supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04740-1.additional file 1. interview guide for the semi-structured interviews with patients/family members and health professionals. key: cord-331487-jh34klbg authors: sivapalan, pradeesh; ulrik, charlotte suppli; bojesen, rasmus dahlin; lapperre, therese sophie; eklöf, josefin viktoria; håkansson, kjell erik julius; browatzki, andrea; tidemansen, casper; wilcke, jon torgny; janner, julie; gottlieb, vibeke; meteran, howraman; porsbjerg, celeste; madsen, birgitte lindegaard; moberg, mia; pedersen, lars; benfield, thomas lars; lundgren, jens dilling; knop, filip krag; biering-sørensen, tor; ghanizada, muzhda; sonne, tine peick; bødtger, uffe christian steinholtz; jensen, sidse graff; rasmussen, daniel bech; brøndum, eva; tupper, oliver djurhuus; sørensen, susanne wiemann; alstrup, gitte; laursen, christian borbjerg; møller, ulla weinrich; sverrild, asger; jensen, jens-ulrik stæhr title: proactive prophylaxis with azithromycin and hydroxychloroquine in hospitalised patients with covid-19 (propac-covid): a structured summary of a study protocol for a randomised controlled trial date: 2020-06-10 journal: trials doi: 10.1186/s13063-020-04409-9 sha: doc_id: 331487 cord_uid: jh34klbg objectives: the aim of this randomised gcp-controlled trial is to clarify whether combination therapy with the antibiotic azithromycin and hydroxychloroquine via anti-inflammation/immune modulation, antiviral efficacy and pre-emptive treatment of supra-infections can shorten hospitalisation duration for patients with covid-19 (measured as "days alive and out of hospital" as the primary outcome), reduce the risk of noninvasive ventilation, treatment in the intensive care unit and death. trial design: this is a multi-centre, randomised, placebo-controlled, 2-arm ratio 1:1, parallel group double-blind study. participants: 226 participants are recruited at the trial sites/hospitals, where the study will take place in denmark: aalborg, bispebjerg, gentofte, herlev, hillerød, hvidovre, odense and slagelse hospitals. inclusion criteria: • patient admitted to danish emergency departments, respiratory medicine departments or internal medicine departments • age≥ 18 years • hospitalized ≤48 hours • positive covid-19 test / diagnosis during the hospitalization (confirmed). • men or non-fertile women. fertile women* must not be pregnant, i.e. negative pregnancy test must be available at inclusion • informed consent signed by the patient *defined as after menarche and until postmenopausal (no menstruation for 12 months) exclusion criteria: • at the time of recruitment, the patient uses >5 lo2/min (equivalent to 40% fio2 if measured) • known intolerance/allergy to azithromycin or hydroxychloroquine or hypersensitivity to quinine or 4-aminoquinoline derivatives • neurogenic hearing loss • psoriasis • retinopathy • maculopathy • visual field changes • breastfeeding • severe liver diseases other than amoebiasis (inr> 1.5 spontaneously) • severe gastrointestinal, neurological and hematological disorders (investigator-assessed) • egfr <45 ml/min/1.73 m2 • clinically significant cardiac conduction disorders/arrhythmias or prolonged qtc interval (qtc (f) of> 480/470 ms). • myasthenia gravis • treatment with digoxin* • glucose-6-phosphate dehydrogenase deficiency • porphyria • hypoglycaemia (blood glucose at any time since hospitalization of <3.0 mmol/l) • severe mental illness which significantly impedes cooperation • severe linguistic problems that significantly hinder cooperation • treatment with ergot alkaloids *the patient must not be treated with digoxin for the duration of the intervention. for atrial fibrillation/flutter, select according to the cardiovascular national treatment guide (nbv): calcium antagonist, beta blocker, direct current (dc) conversion or amiodarone. in case of urgent need for digoxin treatment (contraindication for the aforementioned equal alternatives), the test drug should be paused, and ecg should be taken daily. intervention and comparator: control group: the control group will receive the standard treatment + placebo for both types of intervention medication at all times. if part or all the intervention therapy being investigated becomes standard treatment during the study, this may also be offered to the control group. intervention group: the patients in the intervention group will also receive standard care. immediately after randomisation to the intervention group, the patient will begin treatment with: azithromycin: day 1-3: 500 mg x 1 day 4-15: 250 mg x 1 if the patient is unable to take the medication orally by themselves, the medication will, if possible, be administered by either stomach-feeding tube, or alternatively, temporary be changed to clarithromycin 500 mg x 2 (this only in agreement with either study coordinator pradeesh sivapalan or principal investigator jens-ulrik stæhr jensen). this will also be done in the control group if necessary. the patient will switch back to azithromycin when possible. hydroxychloroquine: furthermore, the patient will be treated with hydroxychloroquine as follows: day 1-15: 200 mg x 2 main outcomes: • number of days alive and discharged from hospital within 14 days (summarises both whether the patient is alive and discharged from hospital) ("days alive and out of hospital") randomisation: the sponsor (chronic obstructive pulmonary disease trial network, cop:trin) generates a randomisation sequence. randomisation will be in blocks of unknown size and the final allocation will be via an encrypted website (redcap). there will be stratification for age (>70 years vs. <=70 years), site of recruitment and whether the patient has any of the following chronic lung diseases: copd, asthma, bronchiectasis, interstitial lung disease (yes vs. no). blinding (masking): participants and study personnel will both be blinded, i.e. neither will know which group the participant is allocated to. numbers to be randomised (sample size): this study requires 226 patients randomised 1:1 with 113 in each group. trial status: protocol version 1.8, from april 16, 2020. recruitment is ongoing (first patient recruited april 6, 2020; final patient expected to be recruited october 31, 2020). trial registration: clinicaltrials.gov identifier: nct04322396 (registered march 26, 2020) full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. the study protocol has been reported in accordance with the standard protocol items: recommendations for clinical interventional trials (spirit) guidelines (additional file 2). the drug is approved and marketed in denmark for the prevention and treatment of malaria, for the treatment of rheumatoid arthritis, discoid and systemic lupus erythematosus and juvenile idiopathic arthritis. manufacturing, packaging and labelling of imp: the trial drugs (imp) are manufactured by glostrup pharmacy by pharmacist kristian østergaard nielsen. placebo capsules are thus made similar to the intervention medicine. the drug (and placebo) are labelled, according to appendix 13. glostrup pharmacy has a key for blinding. therefore, it will always be possible to unblind a patient if indicated. investigator must notify sponsor on grounds if a patient is unblinded. medical professionals dispense the imp daily during hospitalization, except for patients preferring to handle their medication themselves. in the latter case, patient will fill in a medication diary (provided at randomisation). for all patients who are discharged during the intervention period, a medication diary will be provided. the medication diary is subsequently collected. exactly the amount of medication or placebo that the patient is required to take during the study periode will be provided, but for patients who do not take all the medication (protocol deviation), the remaining medication will be collected by the study staff. the patient will receive a follow-up phone call to check whether they have adhered to the medication schedule according to the trial protocol. proactive prophylaxis with azithromycin and chloroquine in hospitalised patients with covid19 (propac-covid) 1.1 hypothesis: in patients with acute hospital admission, a positive test for 2019-ncov and symptoms of covid-19 disease, treatment with virus-modifying agent hydroxychloroquine as well as virusimmunomodulatory and antibacterial drug azithromycin can lead to shorter hospitalisation and fewer admissions to the intensive care unit. the aim of this randomised gcp-controlled trial is to clarify whether combination therapy with macrolide azithromycin and hydroxychloroquine via anti-inflammation/immune modulation, antiviral efficacy and pre-emptive treatment of supra-infections can shorten hospitalisation duration (measured as "days alive and out of hospital"as the primary outcome), reduce the risk of non-invasive ventilation, treatment in the intensive care unit and death. in the ongoing coronavirus pandemic, covid-19, with its origin in wuhan, china, there is still sparse data on the course, risk of various complications, and the best possible treatment of patients admitted to hospital to ensure best possible survival and reducing length of stay at hospital. the most frequent symptoms are fever (> 80%) and cough (70-80%), together with radiologically fingdings of "ground-glass infiltrates" or "patchy infiltrates" in the patients with the most severy ill patients (86%), compatible with severe viral pneumonitis (1, 2) . the length of hospitalisation is observed to be relatively long, 10-15 days (3) , which in itself is a problem as hospitals can quickly reach the maximum capacity for hospitalisation and the proportion of patients who become critically ill have, based on the observations reported so far, had a mortality rate of> 60% (4), and overall mortality for admitted patients in china with covid-19 infection is apparently unusually high for viral respiratory tract infections with an estimate of 25% (2). only specific data on patients with chronic obstructive pulmonary disease (copd) have been reported in a few studies, but the risk of in-hospital death appears to be very high (or 5.4 [95% ci 0.96-30.40]) (2) . proactive prophylaxis with azithromycin and chloroquine in hospitalised patients with covid-19 (propac-covid) 6 despite the rapid spread of the disease globally, there is no solid data yet to recommend any specific treatments, and by that, symptomatic, organ supportive therapy is recommended, and in case of progression to severe acute respiratory failure mechanical ventilation (5) . a high incidence of bacterial super-infections has been reported in patients with covid-19 who died (50%) compared to survivors (1%) (p <0.0001), and likewise, an incidence of septic shock of 70% and 0%, respectively (2) . thus, there is an urgent need for treatments that can improve the course of the diseases in the individual patients, including positive impact on risk for hospital admission, duration of hospitalisation, risk of secondary infections and death. azithromycin is a macrolide antibiotic that has shown convincing efficacy in several studies in recent years to reduce hospitalisation-related exacerbations in copd (6, 7) , and to reduce exacerbationrate in asthma (8) and non-cystic fibrosis bronchiectasis (9) . at the same time, it has been shown that azithromycin has a distinct effect by down-regulating airway inflammation by reducing cxcl1, tnf-alpha, il-13 and il-12p40 (10) . furthermore, a strong association has also been reported between survival from acute respiratory distress syndrome (ards) and administration of azithromycin (hr for 90 days of death for all causes: 0.49 [95% ci 0.27 -0.87] in a well-conducted study (11) . furthermore, it has been consistently observed in several recent publications that azithromycin itself appears to have an antiviral effect on a number of several viruses causing respiratory tract infections, such as respiratory syncytial virus (rsv) (12) , rhinovirus (13) and zika virus (14) . hydroxychloroquine has been marketed since 1934, originally developed for prophylaxis and treatment of malaria, but has for years also been used an anti-inflammatory agent for rheumatic diseases. large daily doses (up to 400 mg a day) of hydroxychloroquine are prescribed over many years to patients with arthritis such as systemic lupus erythematosus and rheumatoid arthritis for anti-inflammatory purposes, which is generally well-tolerated (16) . but in addition to these effects, it is well described that the drug has an antiviral effect especially against flavivirus, retrovirus and coronavirus by inhibiting a number of low-ph-dependent steps in virus replication, as well as by inhibiting the ph-dependent endosomal mediated viral uptake in cells (15) . the drug is well tolerated even with high dosage, for up to five years and there is no signal for birth defects with usage of the drug summarised by savarino et al. (15) . cell studies with primate cells infected with the coronavirus that induced sars-1 (formerly called sars) have shown that chloroquine, in a dose-dependent manner, inhibits the ability of the corona virus to infect cells and to spread among cells (17) . thus, several researchers and health care professionals have, during the present sars-cov-2 pandemic, have proposed studies examining hydroxychloroquine/chloroquine as treatment for patients with covid-19 disease (18, 19) . proactive prophylaxis with azithromycin and chloroquine in hospitalised patients with covid-19 (propac-covid) 7 the study will clarify whether treatment with azithromycin in combination with hydroxychloroquine for 15 days from the time of hospital admission with diagnosed covid-19 disease may reduce the length of hospitalisation, the risk of admission to the intensive care unit, treatment with non-invasive ventilation and death. the study will also clarify whether this treatment can reduce the need for oxygen supplementation (time for breathing on its own without oxygen supplementation) or for regular long-term oxygen therapy oxygen supplementation ("home oxygen"). if the treatment also improves the course of covid-19 disease in patients with pre-existing lung disease, a very large number of patients could benefit from the treatment immediately. the study originates from the danish national non-commercial lung research network cop:trin (chronic obstructive pulmonary disease: trial network). 3.1 design: randomised, good-clinical-practice-monitored, placebo-controlled, double-blind study. see point 12. inclusion criteria: interactions should be taken into account if the patient is taking other medications. for azithromycin, this includes antacids, ergotamine derivatives, colchicine and cyclosporine. for hydroxychloroquine, these include antidiabetic agents, tricyclic antidepressants, antipsychotics, halofantrine, cyclosporine, mefloquine, antiepileptic drugs, praziquantel and agalsidase. as there is no specific treatment for covid-19, standard assessment and treatment is based on organ supportive therapy such as oxygen therapy (central), fluid therapy, antibiotic therapy for secondary infections. if the disease progress to severe acute respiratory failure, the patients will often require referral to an intensive care unit for mechanical ventilation. in addition, danish national guidelines for handling of in-hospital covid-19 patients can be obtained from www.lungemedicin.dk or from the open access journal european respiratory clinical journal (at present in press). the sponsor generates a randomisation sequence. randomisation will be in blocks of unknown size and the final allocation will be via an encrypted website (redcap), where also inclusion and exclusion criteria are required to be filled in correctly in order to randomise a patient. allocation will be stratified for age (>70 years vs. <=70 years), site of recruitment and whether the patient has any of the following chronic lung diseases: copd, asthma, bronchiectasis, interstitial lung disease (yes vs. no). the primary daily project management is carried out by the project manager. in addition, a project group (investigators), consisting of doctors from the departments involved, is trained to assist the project manager with the recruitment, sampling and follow-up of patients. all medical decisions regarding patients will be taken by a physician. data is collected in case report forms (crf) for each individual patient. prior to consent to participate in the trial, we will only assess the specific information needed to assess inclusion and exclusion criteria. no other information will be accessed. it is the attending physician who asks if patients are interested in hearing more about the trial. if yes, an investigator is contacted, who will inform the patient about the trial. as part of the study, all patients will be regularly monitored for oxygen saturation, heart rate, blood pressure, respiratory rate and temperature during hospitalisation. the following information will also be obtained: all this information is passed on to the investigator. the information from the medical records is required to calculate demographic data, medication data and outcomes in the trial. no information that is not required according to the protocol will be obtained. case report form is archived at the departments involved for 15 years. a separate database is created in redcap (www.projectredcap.org) for data management. *the blood samples include haemoglobin (hb), leukocytes + differential count, thrombocytes, creactive protein (crp), na+, k+, albumin, creatinine, urea, amylase, alkalic phosphatase, beta-2-microglubulin, fibrinogen, glucose, tsh, inr, billirubin, d-dimer, aptt, calcium, triglycerides, ferritin and lactate dehydrogenase (ldh). these blood tests will also be recommended daily for covid patients outside studies in the recommendation of the danish lung medicine association. **when screening for the study, any ecg from within the last 3 days can be used. ***a follow-up ecg can be recorded during any remaining days of the hospital admission. ****only in patients with copd. neither patients nor study staff will know which group the patient is allocated to. the medicine will be marked neutral, e.g. "azithromycin group a" and "azithromycin group b" and the same for hydroxychloroquine. note: if the patient is receiving azithromycin prophylaxis, common practice is followed: the prophylaxis is paused and then restarted as usual. control group: the control group will receive the standard treatment + placebo for both types of intervention imp at all times. if part or all the intervention therapy being investigated becomes standard treatment during the study, this may also be offered to the control group. intervention group: the patients in the intervention group will also receive standard care. immediately after randomisation to the intervention group, the patient will begin treatment with : azithromycin: if the patient is unable to take the medication orally by themselves, the medication will, if possible, be administered by either stomach-probe, or alternatively, temporary be changed to clarithromycin 500 mg x 2 (this only in agreement with either study coordinator pradeesh sivapalan or principal investigator jens-ulrik staehr jensen). this will also be done in the control group if necessary. the patient will switch back to azithromycin when possible. hydroxychloroquine: furthermore, the patient will be treated with hydroxychloroquine as follows: follow-up is done on days 14, 29, 90 and 365 days, by accessing the electronic medical record system. the specific information obtained, and its purpose can be found in section 3.3.3. the summary of product characteristics for azithromycin suggests 500mg/day for three days or 500mg/day for one day and then 250mg daily for four days. however, other clinical studies have found a positive effect of a daily dose of 250 mg for prolonged periods as prophylactic treatment. mortality among hospitalised patients with covid-19 is quite high and the median time for hospitalisation is 10-15 days, so it seems reasonable to give patients prophylactic dose for 12 days. the dosing of hydroxychloroquine follows the summary of product characteristics. regarding other treatment with antibiotics: if antibiotic therapy is deemed indicated to the patient due to e.g. pneumonia or if it becomes standard therapy, piperacillin-tazobactam should be given as an empirical treatment at a dose adjusted to renal function. in case of penicillin allergy, cefuroxime is also given at a dose appropriate to renal function, weight and age. when positive microbiology is available, immediately switch to targeted treatment. if specific suspicion of atypical pneumonia is raised, ciprofloxacin is administered at a dose of corresponding to kidney function and concomitant examination for atypical pneumonia will be performed. if negative, ciprofloxacin is discontinued. if positive, ciprofloxacin treatment is continued for the duration of treatment corresponding to the microorganism detected. if there is a specific need for treatment with macrolide and where other options are not available (e.g. allergy to fluoroquinolones, or when there is an estimated need for combination treatment of e.g. legionella pneumonia), consult with an investigator, and in this case it may be decided to discontinue azithromycin (active) or azithromycin placebo. in this case, treatment stops without unblinding. furthermore, ecg recordings during the treatment period will be analysed with focus on qtc. at qtc (f)> 480/470 ms for respectively women and men, imp will be discontinued for safety reasons (but the patient remains in the study). primary endpoint: this requires 226 patients randomised 1:1 with 113 in each group. this is a fixed sample size. it is assumed that most patients complete the intervention. however, for interim analysis, the data and safety monitoring board (dsmb) may recommend the steering committee to expand sample size. frequency and depth are determined by the gcp units. initiation visits and the first monitoring visits to all centres will be conducted off-site, i.e. without a physical meeting, due to the sars-cov-2 pandemic. consent sheets will be scanned into an online system (redcap or journal system) that can be accessed by gcp monitors. after recruiting half the sample size (approximately 113 patients), an interim analysis will be performed focusing on safety. an external data and safety monitoring board is appointed. the interim analysis will be prepared and presented by physician josefin eklöf. the groups will be presented as "group a" and "group b" and dsmb will only be unblinded if they ask the steering committee for the study on this. as part of ususal care, blood samples are taken daily from the time of inclusion and as long as the patient is admitted. blood samples include haemoglobin (hb), leukocytes + differential count, thrombocytes, c-reactive protein (crp), na+, k+, albumin, creatinine, urea, amylase, alkalic phosphatase, beta-2-microglobulin, fibrinogen, glucose, tsh, d-dimer, aptt, calcium, triglycerides, ferritin, bilirubin, alat, inr, and lactate dehydrogenase (ldh), see table 1 . these blood samples are analysed at the hospitals. in addition, supplemental blood tests and material obtained with nasal swaps will be performed according to the sub-study protocols. material from this will be included in a research biobank for the trial, and after completion of the trial in another regional biobank. the trial is expected to end in february 2021, and the material will then be transferred to the regional biobank. for the present trial, the results of blood tests are collected from the patient record. the treating physician may at any time discontinue intervention with imp if, in clinical and/or paraclinical assessment, it is deemed contraindicated. serious side effects to regular blood sampling (venous puncture) are rare. frequent (5-15%) can be seen transient discoloration of skin around the insertion site. chest x-rays correspond to a radiation dose of approx. 0.1 millisievert (msv). this should be compared with the average background radiation in denmark of approx. 3 msv per year. there are no documented adverse effects of the radiation dose received by chest x-rays in the literature. therefore, we believe that the study is not associated with any risks or side effects. • with pigment change requires careful dosing and careful control. when using rheumatologic doses, eye examination by an ophthalmologist is recommended before starting treatment and with follow-up to check for any eye manifestations that may arise. annual monitoring after 5 years of treatment is recommended, however in risk patients initially annual control, see also chloroquine derivatives (inflammatory rheumatic diseases), side effects. • with cardiomyopathy can be fatal. • with macular degeneration is seen and may be irreversible. • with reversible corneal changes with oedema and blemishes can cause blurred vision or photophobia. • with blurred vision accommodation is dose-dependent and reversible. • in malaria treatment and prophylaxis, fewer and milder side effects occur. **prolonged qt interval has been seen in patients with particular risk factors for it. ***acute generalized exanthematous pustulosis must be distinguished from psoriasis. psoriasis exacerbation may occur. may be associated with fever and hyperleukocytosis. an adverse reaction (ar) is defined as any adverse and undesirable reaction to a trial drug regardless of dose. an adverse event (ae) is defined as any adverse event in a patient or subject in a clinical trial following treatment with a drug, without necessarily linking this treatment to the adverse event. since the trial drugs are well known and have been used for many years, we will only record side effects not mentioned in the respective drug summary of the trial drug. a severe adverse reaction or event (sar/sae) is defined as an event or adverse event that, regardless of dose, results in death, is life-threatening, results in hospitalization or prolongs hospitalization, results in significant or persistent disability or incapacity, or leading to a congenital anomaly or malformation. investigators must immediately (= within 24 hours) report serious incidents and serious adverse reactions (saes and sars) to the sponsor regardless of whether they are described in the respective product summary. this allows the sponsor to assess the benefits and risks along the way in the study. events and adverse events recorded during the period from the patient have received the first dose of trial medication up to and including day 15. recording and reporting of all events and adverse events will end when the trial drug is stopped. a high degree of comorbidity and death is seen in this patient group and therefore it is also expected that prolonged admissions, re-admissions, niv, respirator treatment and death will occur in this patient group. therefore, these parameters will not be considered as a sae. all incidents and registered side effects are reported at the end of the trial in a final report to the danish medicines agency. all serious suspected adverse reactions must be reported annually together with a report on the safety of the subjects and sent to the the danish medicines agency (lmst) and the danish national committee on health research ethics (vek). the product summary of the trial drugs is used to assess whether a serious adverse event is unexpected and thus possibly a suspected unexpected serious adverse reactions (susar). in the event of a fatal or life-threatening susar, this must be registered and reported to lmst and vek within 7 days of the sponsor becoming aware of it. no later than 8 days after the report, the sponsor must provide lmst and vek with all relevant information about the sponsors and investigators' follow-up on the event. all other susars are reported to lmst and vek within 15 days of the sponsor becoming aware of them. the report must be followed up by a detailed written report, and in both the immediate report and the subsequent report, the investigator must identify the subjects with a personal code number. when reporting deaths, the investigator must provide any additional information that the sponsor may request. the research project is (investigator) initiated by cop:trin. funding has been obtained from the novo nordisk foundation of dkk 2.2 million for sponsor, remuneration of auxiliary personnel, payment of laboratory tests and equipment, as well as for manufaction of imp treatment and placebo. the sponsors and investigators are not financially linked to private companies, foundations, etc. in this research project. medical expenses are covered, if not obtained from other sources, by the section for respiratory medicine research, gentofte hospital. to the extent possible, the section for respiratory medicine research, gentofte hospital supports follow-up for endpoints and otherwise by appointment. patients are not paid for participation in the trial. the consent gives the primary investigator, monitor and any control authority direct access to obtain information in the patient's medical record, etc., including electronic record, in order to see information about the subject's health conditions which are necessary as part of the implementation of the research project and for control purposes, including self-monitoring, quality-control etc. the project group that has designed and conducted this study has the right to data and the right (and duty) to publish based on data. project management manages data and invites members of the study group to publications. all sites that recruit patients are entitled to at least one authorship on the primary publication, and for every 10 patients recruited, the site is entitled to an extra authorship. sites that have not participated in the design of the study are entitled to a maximum of 3 authorships. it is the opinion of the steering committee that knowledge sharing creates more and better scientific results. requests for knowledge sharing from other groups may be submitted to project management (jens-ulrik jensen, charlotte ulrik, pradeesh sivapalan) who will evaluate primarily and who, if the project is found suitable, will discuss it with the cop:trin steering committee. project management has the first right to undertake sub-studies but may well assign projects to other contributors. in that case, the following considerations will be significant in the assessment: 1) participation in the design phase of this rct and at what level, and 2) number of patients recruited at a site. if the hypothesis to be investigated is not planned to be examined by our group, we will allow the use of our data if the steering committee finds the project scientifically sound and, if appropriate, a collaboration with members of the cop:trin steering committee will be proposed. however, it should be emphasized that data is used for a specific purpose, not for future purposes in general. this becomes conditional by the steering committee for data to be used in a sound way to test hypotheses with relevant scientific content. information regarding subjects are processed and stored in accordance with the data protection regulation (gdpr), the data protection act and the health act and the project is properly notified in accordance with applicable rules and laws to the appropriate authorities. all project results will be sought published in scientific contexts, including international journals. this will happen regardless of whether the result is positive, negative or inconclusive. the study is conducted in accordance with the declaration of helsinki and is carried out in accordance with the rules of the personal data act and the health act. the study has been registered at the danish data protection agency. recruitment and inclusion will take place as previously described (section 3.3.1). participation requires a signed statement of consent. patients can withdraw their participation consent and withdraw from the research project at any time without this having any effect on their right to current or future treatment. furthermore, the patient is entitled to bring a bystander to the information interview and is entitled to reflection time before any declaration of consent is signed. the important objective of the study is to investigate whether pro-active and pre-emptive treatment against covid-19 can reduce the length of hospitalisation and the risk of intensive care and improve the survival of patients -an area that has so far been poorly researched and where the need for evidence-based guideline for handling and processing is large and very urgent. potential disadvantages and side effects are described in the separate section 5. among other things, it appears that the likelihood of serious adverse reactions to both treatment and examinations is rare. in addition, the treating physician can always discontinue treatment if it is considered contraindicated. placebo is given patients allocated to the control group as no specific standard medical treatment is available. the experimental method and statistical analyses have been carefully considered in order to be able to disseminate and apply relevant and secure research results to clinical practice. based on the above considerations, we believe that the experiment is sound ethically sound and can be conducted without exposing the test participant to unjustifiable risks. at each trial centre, screening of patients admitted with a positive sars-cov-2 test is performed. patients are assessed against the inclusion and exclusion criteria of the attending physician who receives the patient's consent to contact the investigator. the investigator then contacts the patient for recruitment to the study. disclosure of information about the study and obtaining informed consent may also be undertaken by other healthcare professionals. this includes research assistants (medical students), clinical nursing specialists and project nurses (see below for specific requirements). these are all separately trained in the task and have the opportunity to call a physician should any medical issues arise. they can also contact the coordinating investigator as well as a hotline team for the trial should any questions arise about informed consent. this hotline is available 24 hours a day. all patients are offered a consultation with a physician if they ask for it. for project nurses, the following applies specifically: i) must have at least 5 years of seniority. these requirements are verified by primary investigator from each site that afterwards creates a document for these individuals from which the above specific requirements are verified. this document is dated and signed. if a patient is considered suitable, the person will be invited to participate in the project. participation in the trial is voluntary. informed consent is obtained from the participants of the trial acc. to executive order no. 1149 of 30 september 2013 on information and consent for participation in health science research projects and on notification and supervision of health science research projects. the first contact with the the potential participant in the trial will be at admission to one of the participating departments. participant information is provided both orally and in writing, and the patient is informed that they are entitled to 24 hours of reflection time before consent is given for participation in the trial. participants who wish to do so themselves after the period of reflection time may give consent in connection with the information meeting. the right to a bystander is ensured by the patient being able to bring a bystander, however, subject to covid isolation rules. if no bystanders come to the first call, they are ensured afterwards to a bystander, when the patient is out of isolation. it is ensured that the conversations are undisturbed by using the patient's isolation room. if the doctor carries a "pager" or telephone, these are handed in prior to the call. the trial participant will be provided with the document "the research subject's rights in a health science research project", which contains information about confidentiality, access to documents and access to complaints. the subjects are protected under the personal data processing act. the trial has been reported to the regional science ethics committee, the danish medicines agency and the danish data protection agency. it must be ensured at all times that subjects have consented to participate in clinical trials. if an isolated subject with covid-19 can sign consent declaration via electronic tool, this can be used instead of consent with signature. this can be, for example, a mobile phone, an ipad, a laptop with secure identification, for example by an easy id (or other solution that meets the oces standard). if the above described solution is not possible, the following solutions can be used as temporary documentation for the consent: • copy of signed consent declaration -e.g. using camera: the subject can sign the consent form as usual. since the signed form must not leave the isolation room, the signature can be documented in the form of a photograph of the signed form, for example through a window. • if the test subject cannot sign the consent declaration himself, e.g. due to problems with having electronic equipment in the room, or obtaining documentation for the consent out of the room, the witness can sign on behalf of the subject: if the subject verbally consents, a witness can on behalf of the subject sign the consent form. for both of the above solutions, documentation (photo and witness signature) will be filed in the investigator's section of the trial master file (tmf). furthermore, it is ensured that the data protection regulation and the data protection act are complied with, although documentation of the consent is temporarily different than it usually is. if the situation is normalised, the correct signed consent form must be obtained from the subject as soon as possible. regular monitoring and quality control of the study will be carried out. if the physician responsible for the study deems it necessary, the physician may during treatment take the subject out of the study. the physician may also terminate the study at any time if there is a medical justification (such as the development of allergies to medicines), a safety risk or a requirement from the authorities. the test subject may also withdraw their informed consent and withdraw from the investigation at any time, as mentioned in the above paragraph. patients who participate in these studies and who believe they have suffered injury can seek compensation through the patient compensation (http://patienterstatningen.dk/) cf. danish law. common (1-10%) powerlessness, decreased appetite. vomiting, taste disorders. decreased lymphocyte count. decreased serum bicarbonate. arthralgia. headaches, paraesthesia, dizziness. skin itching, rash uncommon (0.1-1%) pain. hepatitis, oral candidiasis. dyspnea, pneumonia, oedema. eosinophilia, leukopenia, neutropenia. elevated serum bicarbonate, hyperchloremia, hyperglycaemia, hyperkalaemia, hypernatremia, hypokalaemia, hyponatraemia. arthritis, back pain. nervousness, somnolence. facial oedema liver impact. agitation. acute generalized exanthematous pustulosis*, allergic reactions*, angioedema*, hypersensitivity. not known fulminant hepatitis, hepatotoxicity, hepatic insufficiency, pancreatitis, pseudomembranous colitis. arrhythmias, extended qt interval, hypotension, torsades de pointes tachycardia. haemolytic anaemia, thrombocytopenia dress -drug reaction with eosinophilia and systemic symptoms, erythema multiforme, stevens-johnson syndrome, toxic epidermal necrolysis. anaphylactic reaction. acute renal failure *in case of allergic reactions, including acute generalized exanthematous pustulosis and dress, azithromycin should be discontinued. hydroxychloroquine: very common (> 10%) abdominal pain common (1-10%) eating refusals. diarrhoea, vomiting. emotional lability, headaches. skin itching, rash. accommodation difficulty aggravation of porphyria, hypoglycaemia. myopathy. extrapyramidal genes, cramps, neuropathy, palsy, psychosis, suicidal behaviour. acute generalized exanthematous pustulosis***, exfoliative dermatitis, erythema multiforme, photosensitivity, stevens-johnson syndrome, toxic epidermal necrolysis. allergic reactions (including dress syndrome proactive prophylaxis with azithromycin and chloroquine in hospitalised patients with covid-19 clinical characteristics of coronavirus disease 2019 in china clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study clinical characteristics of refractory covid-19 pneumonia in wuhan, china clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study care for critically ill patients with covid-19 azithromycin maintenance treatment in patients with frequent exacerbations of chronic obstructive pulmonary disease (columbus): a randomised, double-blind, placebo-controlled trial azithromycin for prevention of exacerbations of copd effect of azithromycin on asthma exacerbations and quality of life in adults with persistent uncontrolled asthma (amazes): a randomised, double-blind, placebo-controlled trial proactive prophylaxis with azithromycin and chloroquine in hospitalised patients with covid-19 (propac-covid) 23 effect of azithromycin maintenance treatment on infectious exacerbations among patients with non-cystic fibrosis bronchiectasis: the bat randomized controlled trial randomised, double-blind, placebo-controlled trial with azithromycin selects for anti-inflammatory microbial metabolites in the emphysematous lung adjunctive therapy with azithromycin for moderate and severe acute respiratory distress syndrome: a retrospective, propensity score-matching analysis of prospectively collected data at a single center azithromycin attenuates airway inflammation in a mouse model of viral bronchiolitis azithromycin induces anti-viral responses in bronchial epithelial cells azithromycin protects against zika virus infection by upregulating virus-induced type i and iii interferon responses effects of chloroquine on viral infections: an old drug against today's diseases? the role of antimalarial agents in the treatment of sle and lupus nephritis chloroquine is a potent inhibitor of sars coronavirus infection and spread chloroquine for the 2019 novel coronavirus sars-cov-2 breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of covid-19 associated pneumonia in clinical studies key: cord-330573-rr2r8245 authors: stockmann, helena; keller, theresa; büttner, stefan; jörres, achim; kindgen-milles, detlef; kunz, julius valentin; leebmann, josef; spies, claudia; träger, karl; treskatsch, sascha; uhrig, alexander; willam, carsten; enghard, philipp; slowinski, torsten title: cytoresc – “cytosorb” rescue for critically ill patients undergoing the covid-19 cytokine storm: a structured summary of a study protocol for a randomized controlled trial date: 2020-06-26 journal: trials doi: 10.1186/s13063-020-04501-0 sha: doc_id: 330573 cord_uid: rr2r8245 objectives: approximately 8 10 % of covid-19 patients present with a serious clinical course and need for hospitalization, 8% of hospitalized patients need icu-treatment. currently, no causal therapy is available and treatment is purely supportive. the main reason for death in critically ill patients is acute respiratory failure. however, in a number of patients a severe hyperinflammatory response with excessively elevated proinflammatory cytokines causes vasoplegic shock resistant to vasopressor therapy. a new polystyrene-based hemoadsorber (cytosorb®, cytosorbents inc., new jersey, usa) has been shown to adsorb effectively cytokines and other middle molecular weight toxins this way reducing their blood concentrations. this has been routinely used in clinical practice in the eu for other conditions where a cytokine storm occurs and an observational study has just been completed on covid-19 patients. we hypothesized that the extracorporeal elimination of cytokines in critically ill covid-19 patients with suspected hyperinflammation and shock may stabilize hemodynamics and improve outcome. the primary endpoint is time until resolution of vasoplegic shock, which is a well implemented, clinically relevant endpoint in critical care studies. trial design: phase iib, multicenter, prospective, open-label, randomized, 1:1 parallel group pilot study comparing the additional use of “cytosorb” to standard of care without “cytosorb”. participants: patients are recruited from the intensive care units (icus) of 7 participating centers in germany (approximately 10 icus). all patients aged 1880 with positive polymerase chain reaction (pcr) test for sars-cov-2, a c-reactive protein (crp) ≥ 100 mg/l, a procalcitonin (pct) < 2 ng/l, and suspected cytokine storm defined via a vasoplegic shock (norepinephrine > 0.2 μg/min/kg to achieve a mean arterial pressure ≥ 65mmhg). patients are included irrespective of indication for renal replacement therapy. suspected or proven bacterial cause for vasoplegic shock is a contraindication. intervention and comparator: within 24 hours after meeting the inclusion criteria patients will be randomized to receive either standard of care or standard of care and additional “cytosorb” therapy via a shaldon catheter for 3-7 days. filter exchange is done every 24 hours. if patients receive antibiotics, an additional dose of antibiotics is administered after each change of “cytosorb” filter in order to prevent underdosing due to “cytosorb” treatment. main outcomes: primary outcome is time to resolution of vasoplegic shock (defined as no need for vasopressors for at least 8 hours in order to sustain a map ≥ 65mmhg) in days. secondary outcomes are 7 day mortality after fulfilling the inclusion criteria, mortality until hospital discharge, interleukin-6 (il-6) measurement on day 1 and 3, need for mechanical ventilation, duration of mechanical ventilation, duration of icu-stay, catecholamine dose on day 1/2/3 after start of “cytosorb” and acute kidney injury. randomization: an electronic randomization will be performed using the study software secutrial® administered by the clinical study center (csc) of the charité – universitätsmedizin berlin, germany. randomization is done in blocks by 4 stratified by including center. blinding (masking): the trial will be non-blinded for the clinicians and patients. the statistician will receive a blinded data set, so that all analyses will be conducted blinded. numbers to be randomized (sample size): as this is a pilot study with the goal to examine the feasibility of the study design as well as the intervention effect, no formal sample size calculation was conducted. a total number of approximately 80-100 patients is planned (40-50 patients per group). safety assessment is done after the inclusion of each 10 patients per randomization group. trial status: please see the study protocol version from april 24 2020. recruitment of patients is still pending. trial registration: the study was registered on april 27 2020 in the german registry of clinical trials (drks) under the number drks00021447. full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. (continued from previous page) participants: patients are recruited from the intensive care units (icus) of 7 participating centers in germany (approximately 10 icus). all patients aged 18-80 with positive polymerase chain reaction (pcr) test for sars-cov-2, a c-reactive protein (crp) ≥ 100 mg/l, a procalcitonin (pct) < 2 ng/l, and suspected cytokine storm defined via a vasoplegic shock (norepinephrine > 0.2 μg/min/kg to achieve a mean arterial pressure ≥ 65mmhg). patients are included irrespective of indication for renal replacement therapy. suspected or proven bacterial cause for vasoplegic shock is a contraindication. intervention and comparator: within 24 hours after meeting the inclusion criteria patients will be randomized to receive either standard of care or standard of care and additional "cytosorb" therapy via a shaldon catheter for 3-7 days. filter exchange is done every 24 hours. if patients receive antibiotics, an additional dose of antibiotics is administered after each change of "cytosorb" filter in order to prevent underdosing due to "cytosorb" treatment. main outcomes: primary outcome is time to resolution of vasoplegic shock (defined as no need for vasopressors for at least 8 hours in order to sustain a map ≥ 65mmhg) in days. secondary outcomes are 7 day mortality after fulfilling the inclusion criteria, mortality until hospital discharge, interleukin-6 (il-6) measurement on day 1 and 3, need for mechanical ventilation, duration of mechanical ventilation, duration of icu-stay, catecholamine dose on day 1/2/3 after start of "cytosorb" and acute kidney injury. randomization: an electronic randomization will be performed using the study software secutrial® administered by the clinical study center (csc) of the charité -universitätsmedizin berlin, germany. randomization is done in blocks by 4 stratified by including center. blinding (masking): the trial will be non-blinded for the clinicians and patients. the statistician will receive a blinded data set, so that all analyses will be conducted blinded. numbers to be randomized (sample size): as this is a pilot study with the goal to examine the feasibility of the study design as well as the intervention effect, no formal sample size calculation was conducted. a total number of approximately 80-100 patients is planned (40-50 patients per group). safety assessment is done after the inclusion of each 10 patients per randomization group. trial status: please see the study protocol version from april 24 2020. recruitment of patients is still pending. trial registration: the study was registered on april 27 2020 in the german registry of clinical trials (drks) under the number drks00021447. full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. keywords: covid-19, randomized controlled trial, protocol, cytokine storm, vasoplegic shock, extracorporeal cytokine elimination supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04501-0. written informed consent is obtained from all patients. if a patient is not able to give written informed consent himself, and a legal representative exists, the consent of the representative will be obtained in advance. for all other patients incapable of informed consent, a legal guardian will be requested immediately. if the patient regains consciousness during the course of the study, he or she will be informed about the study and can subsequently consent to participate in the study. if the patient does not retrospectively agree with the study, his data will be discarded. if the patient does not regain consciousness, the appointed caregiver decides retrospectively on participation in the study. if the patient dies before urgent care could be installed, the personal data of the person concerned will be evaluated in an anonymized manner. in this way, the protection of the personality and the data protection interests of the person concerned are safeguarded. furthermore, this procedure does not compromise the processing objective of the research project. not applicable for biometry and clinical epidemiology 10 department of internal medicine/infectious diseases and pulmonary medicine publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to acknowledge the valuable and straightforward help of inka gotthardt, grit bugasch, roman weimann, olaf bender, the-hoang do and alexander krannich in all parts of trial design, manuscript generation and bmbf application. authors' contributions ts, pe and hs designed the trial, wrote the study protocol, obtained ethical approval and applied for bmbf funding. tk did the biostatistic design of the trial and wrote the statistical section of the study protocol, ethical approval and bmbf application. hs wrote this manuscript. sb, aj, dkm, jk, jl, cs, kt, st and cw substantially contributed to the study conception and revised the work. all authors read and approved the final manuscript. funding by the german federal ministry of education and research (bmbf) was applied. a decision is still pending. the bmbf will and had no role in the design of the study, collection, analysis, and interpretation of data and in writing the manuscript. all individual patient data on which the results of the publication are based will be made available in anonymized form to scientists who present a reasonable analysis plan. the aim is to make the scientific findings available for other research projects. data requests should be addressed to: torsten. slowinski@charite.de. for data access, the applicant must sign a data access authorization. furthermore, the study protocol, the statistical analysis plan, the patient information and the patient consent form will be made available to all interested persons. these documents are available on an external website for 5 years. the data will be made available for a total of 3 months up to a maximum of 5 years. key: cord-324786-8k81jetq authors: chang, anne b; grimwood, keith; robertson, colin f; wilson, andrew c; van asperen, peter p; o’grady, kerry-ann f; sloots, theo p; torzillo, paul j; bailey, emily j; mccallum, gabrielle b; masters, ian b; byrnes, catherine a; chatfield, mark d; buntain, helen m; mackay, ian m; morris, peter s title: antibiotics for bronchiectasis exacerbations in children: rationale and study protocol for a randomised placebo-controlled trial date: 2012-08-31 journal: trials doi: 10.1186/1745-6215-13-156 sha: doc_id: 324786 cord_uid: 8k81jetq background: despite bronchiectasis being increasingly recognised as an important cause of chronic respiratory morbidity in both indigenous and non-indigenous settings globally, high quality evidence to inform management is scarce. it is assumed that antibiotics are efficacious for all bronchiectasis exacerbations, but not all practitioners agree. inadequately treated exacerbations may risk lung function deterioration. our study tests the hypothesis that both oral azithromycin and amoxicillin-clavulanic acid are superior to placebo at improving resolution rates of respiratory exacerbations by day 14 in children with bronchiectasis unrelated to cystic fibrosis. methods: we are conducting a bronchiectasis exacerbation study (best), which is a multicentre, randomised, double-blind, double-dummy, placebo-controlled, parallel group trial, in five centres (brisbane, perth, darwin, melbourne, auckland). in the component of best presented here, 189 children fulfilling inclusion criteria are randomised (allocation-concealed) to receive amoxicillin-clavulanic acid (22.5 mg/kg twice daily) with placebo-azithromycin; azithromycin (5 mg/kg daily) with placebo-amoxicillin-clavulanic acid; or placebo-azithromycin with placebo-amoxicillin-clavulanic acid for 14 days. clinical data and a paediatric cough-specific quality of life score are obtained at baseline, at the start and resolution of exacerbations, and at day 14. in most children, blood and deep nasal swabs are also collected at the same time points. the primary outcome is the proportion of children whose exacerbations have resolved at day 14. the main secondary outcome is the paediatric cough-specific quality of life score. other outcomes are time to next exacerbation; requirement for hospitalisation; duration of exacerbation; and spirometry data. descriptive viral and bacteriological data from nasal samples and blood markers will also be reported. discussion: effective, evidence-based management of exacerbations in people with bronchiectasis is clinically important. yet, there are few randomised controlled trials (rcts) in the neglected area of non-cystic fibrosis bronchiectasis. indeed, no published rcts addressing the treatment of bronchiectasis exacerbations in children exist. our multicentre, double-blind rct is designed to determine if azithromycin and amoxicillin-clavulanic acid, compared with placebo, improve symptom resolution on day 14 in children with acute respiratory exacerbations. our planned assessment of the predictors of antibiotic response, the role of antibiotic-resistant respiratory pathogens, and whether early treatment with antibiotics affects duration and time to the next exacerbation, are also all novel. trial registration: australia and new zealand clinical trials register (anzctr) number actrn12612000011886. compared to the early 20th century, the prevalence of bronchiectasis has fallen substantially. although regarded as an 'orphan disease' in affluent countries, reports of prevalence of bronchiectasis are increasing [1, 2] . bronchiectasis remains a major contributor to chronic respiratory morbidity [2, 3] and mortality [1, 4] in both indigenous [5] and non-indigenous populations [6] . in our recently completed multicentre study of children newly referred for chronic cough and managed in accordance to a standardised protocol [7] , 31 (9%) of the 346 children had bronchiectasis proven on radiology [8] . in the northern territory in australia, the incidence of bronchiectasis in the first year of life is 118 in 100,000 [9] . the estimated prevalence of bronchiectasis is 1,470 per 100,000 in central australian indigenous children aged below 15 years [10] and 1,600 per 100,000 in alaskan native children [11] . in the united states, reported prevalence in adults range from 4.2 to 271.8 per 100,000 [6] . however, any reported prevalence is likely to be an underestimate as many cases are misdiagnosed or coexist with other diseases like asthma [12] [13] [14] and chronic obstructive pulmonary disease (copd) [15] . even without accounting for these unrecognised cases, globally there are far more patients with bronchiectasis than cystic fibrosis (cf), which has a prevalence of 7.4 to 7.9 per 100,000 in the european union and the united states [14] . effective clinical management reduces both short-and long-term morbidity (and likely mortality) associated with bronchiectasis [16] [17] [18] . there is increasing evidence that intensive treatment of children who either have bronchiectasis or are at risk of developing severe bronchiectasis prevents poor lung function in adulthood [17] [18] [19] [20] . cohort data have shown that approximately 80% of newly diagnosed adults (non-smokers) with bronchiectasis reported symptoms dating back to childhood and that the duration of chronic cough (the most common symptom of bronchiectasis [21] ) was related (r = −0.51, p < 0.001) to lung function at diagnosis [22] . arguably, appropriate overall management and treatment of exacerbations (leading to reduction of persistent symptoms) potentially prevents or reduces deterioration of chronic respiratory disease [23] . determinants of accelerated lung function decline in adults with bronchiectasis are the frequency of hospitalised exacerbations, increased systemic inflammatory markers and pseudomonas aeruginosa infection [24] . amongst other factors, increased mortality risk is associated with the degree of lung function impairment [25] . no prospective data exist in children. our study and a london-based retrospective study found that, with appropriate treatment in specialised centres, lung function improves and can be maintained [18, 20] . however, those with poor lung function at diagnosis, although substantially improved, were likely to still have poor lung function five years later [20] . we also found that the only significant predictor of a decline in forced expiratory volume in one second (fev 1 ) was frequency of hospitalised exacerbations [20] . forced expiratory volume in one second (fev 1 )% predicted decreased by 1.95% with each previous hospitalised exacerbation [20] . as airway injury in children is superimposed upon the physiological changes involving lung growth and development [26, 27] , improvement in childhood bronchiectasis may impact favourably upon future adult lung function. early and effective management of bronchiectasis exacerbations in children may lead to reduced hospitalisations, better quality of life (qol) and improved future adult lung function. antibiotics are one of the key interventions used to treat acute respiratory exacerbations of bronchiectasis [21, 28] . however, it is biologically plausible that antibiotics are not useful for treating some respiratory exacerbations triggered by viral infections. our retrospective study found that 34% of exacerbations were preceded by a viral-like illness [29] . while most respiratory physicians will treat exacerbations intensively (with antibiotics and airway clearance), other doctors do not. those choosing not to use antibiotics routinely argue that most episodes of exacerbations and cough are caused by viral infections and hence do not require antibiotic therapy. this may be appropriate but viral-bacterial interactions in the airways risk prolonged endobronchial bacterial infection that, with the associated inflammatory cascade, may cause further lung injury [23, 30] . better evidence to guide the management of exacerbations in people with bronchiectasis is needed. there are two components of best; here we present the study protocol of the first phase (best-1). the second phase of best (best-2) will address the question "is daily azithromycin non-inferior (within 20% margin) to amoxicillin-clavulanic acid in achieving resolution of exacerbations on day 21?" the protocol for best-2 will be the subject of a later paper. this first phase of our proposed national multicentre double-blind double-dummy randomised controlled trial (rct) is designed to answer our primary questions, as follows. amongst children with non-cf bronchiectasis, does azithromycin improve the resolution of respiratory exacerbations by day 14 compared with placebo, and does amoxicillin-clavulanic acid improve the resolution of respiratory exacerbations by day 14 compared with placebo? our secondary aims are to: 1. determine the effect of azithromycin or amoxicillinclavulanic acid on the qol, systemic inflammation, time to next respiratory exacerbation, and duration of exacerbations; 2. explore factors that predict response to antibiotics, including respiratory pathogens (viruses, bacteria, macrolide-resistant bacteria) present in respiratory secretions and blood markers; and 3. describe the point prevalence and diversity of respiratory viruses, mycoplasma pneumoniae and chlamydia species during exacerbations using sensitive molecular detection techniques. our study tests the primary hypothesis that both oral azithromycin and amoxicillin-clavulanic acid are superior to placebo in improving the resolution rate of respiratory exacerbations by day 14 in children with non-cf bronchiectasis. we are conducting a multicentre, parallel group, double-blind placebo rct (with concealed allocation) to assess the impact of treatment with antibiotics (azithromycin or amoxicillinclavulanic acid) in children with an exacerbation of bronchiectasis. our study plan is summarised in figure 1 . the inclusion criteria are age below 18 years at time of study enrolment; diagnosed with bronchiectasis by a respiratory physician following high resolution computed tomography in the five years immediately prior to study entry or, if diagnosed earlier, have been followed regularly by a respiratory physician for treatment of bronchiectasis; and has experienced two or more respiratory exacerbations in the 18 months prior to study entry. exclusion criteria are current severe exacerbation of bronchiectasis (dyspnoea, hypoxia or hospitalisation), recent (in last 8 weeks) in the entry; cf; liver dysfunction; allergy or sensitivity to penicillin or macrolides; current or recent lower airway infection by a member of the pseudomonas genus group of gram-negative bacteria (in the four months prior to study enrolment); has received antibiotics belonging to the macrolide or penicillin class of antibiotics within three weeks immediately prior to study entry; or is currently receiving oncological treatment. eligible children will be identified from clinics in our centres (brisbane, perth, darwin and melbourne in australia and auckland in new zealand). parents will be approached and informed consent obtained. baseline pre-exacerbation data will be collected ( figure 1 ), parents contacted monthly and children reviewed every three months. parents will be educated specifically on symptoms of exacerbations and asked to contact the research nurse at the onset of an exacerbation. a double-dummy design is planned. if eligibility is fulfilled and after informed consent has been obtained, the child is randomised to one of three arms. at the start of the exacerbation, the child will receive amoxicillinclavulanic acid with placebo-azithromycin, azithromycin with placebo-amoxicillin-clavulanic acid or placeboazithromycin with placebo-amoxicillin-clavulanic acid. amoxicillin-clavulanic acid dose is 22.5 mg/kg/dose (up to 40 kg) twice a day (max 900 mg/dose). azithromycin dose is 5 mg/kg/day, max of 200 mg daily. equivalent volumes in placebo will be given in all arms. all treatments will continue for 14 days. an exacerbation is defined as an increase in sputum volume or purulence, or three or more days of change in cough (> 20% increase in cough score [31] or type (dry to wet) [32] ). we validated this definition in our prospective study and found that the kappa values (between clinicians) of these symptoms and signs were excellent (> 0.75) [33] . daily diaries will also be collected during exacerbations until the scores for two or more days reflect the child's 'baseline' state, which for each child will be established at enrolment, prior to any exacerbations. this assessment consists of a combination of symptoms (daily cough (yes/no), cough quality (wet/dry/none) and cough score [31] averaged over two consecutive days) and signs (sputum colour (if any present) using a colour chart card (bronkotest ltd, london, uk), crackles on chest auscultation). children will be reviewed on days 7 and 14 and at resolution of the exacerbation. the exacerbation is considered 'resolved' when symptoms and signs are the same as 'baseline' state. post exacerbation, the children will be followed-up and clinically evaluated every three months for 18 months or until their next figure 1 overall schematic study design. amox-clav: amoxicillinclavulanic acid; azithro: azithromycin. exacerbation. 'time to next exacerbation' will be determined by the number of days from 'resolution of current exacerbation' to beginning of the next exacerbation. upon enrolment, the child is assigned to the next unique number on the appropriate stratified list. the allocation will be performed by the trial pharmacist at the royal children's hospital in brisbane. randomisation is stratified by site (brisbane, perth, darwin, melbourne, auckland), age (≤ 5 or > 5 years) and underlying aetiology (idiopathic/post-pneumonia or all other causes). the randomisation sequence was computer generated and used permuted blocks. the allocation sequence is concealed at all times throughout the study. the computer generated allocation sequence was prepared by a statistician external to the study team. the placebo medications, specifically manufactured by the institute of drug technology australia limited (melbourne, victoria), have a similar taste and colour to their respective antibiotics. both active medications (amoxicillin-clavulanic acid and azithromycin) are repackaged by the institute of drug technology. thus both the amoxicillin-clavulanic acid and azithromycin and their respective placebos are in identical opaque bottles. for both types of trial medications, equal volumes of water are added using a syringe and needle by punching the seal. adherence will be assessed by parent report and return of empty bottles. all data will be recorded on standardised forms. on enrolment, demographic information (age, gender, ethnicity, household size, and so on), birth history, breast feeding history, prior illness and in utero and household smoke exposure will be recorded, and a physical examination will be performed by a study physician. the primary and secondary outcome measures (see below) are collected at the time points specified above. serious and non-serious adverse effects (nausea, vomiting, diarrhoea, rash) will also be documented and monitored. safety exit points are discussed in end points below. at enrolment (baseline), all children will have a deep nasal swab (ns) specimen collected. in a subset, additional specimens will be collected at baseline and during exacerbations depending on feasibility (some children are unable to attend the study centre at the onset of the exacerbation) and willingness of parents to allow additional venipuncture. these specimens are: a deep ns specimen for respiratory viruses, respiratory bacterial pathogens (with antibiotic susceptibility testing) and other potentially important respiratory pathogens (m. pneumoniae, chlamydia spp) at baseline and at the beginning and resolution of an exacerbation. the technique used is identical to previous studies [34] [35] [36] where the specimens were described as nasopharyngeal swabs. the nss are handled as per our research laboratory protocol (see below). bloods at baseline and at the beginning and end of each exacerbation for c-reactive protein (crp), neutrophilic marker of inflammation (il-6) [37] , serum amyloid a (saa) [33, 38] and markers of viral infection (interferon gamma-inducible protein 10 (ip-10) and il-10). sputum at baseline and at the beginning and end of each exacerbation (when possible) for lower airway microbiology and antibiotic sensitivity. the verbal categorical descriptive score is a validated daily diary score of cough rated on a six-point scale (0 = no cough to 5 = severe cough and cannot perform activities) with increasing scores reflecting greater interference with usual activities. this rating was validated against an objective cough meter measure [31] and changes in cough scores have been shown to reflect changes in objective cough counts [39] . the parent chronic cough quality of life (pc-qol) is a 27-item questionnaire designed to assess the level of frequency of feelings (15 items) and worry (12 items) related to their child's cough. it uses a seven-point likert-type scale with higher scores reflecting less frequency and fewer worry concerns (that is, greater qol) [40, 41] . the minimal important difference is 0.62 determined by the distribution method and 0.9 determined by the anchor method [42] . oropharyngeal sampling under estimates streptococcus pneumoniae carriage by approximately 50% when compared with ns [43] . thus, ns are the preferred method when evaluating the presence of antibiotic-resistant bacteria. culturing, identifying and, when appropriate, serotyping common respiratory bacteria are established techniques at our research laboratory [36, 44] . swabs are stored in skim milk tryptone glucose glycerol broth medium at −80°c before being batch processed for typical respiratory bacterial pathogens, notably haemophilus influenzae (including strains of non-typeable h. influenzae), moraxella catarrhalis and s. pneumoniae. batches of swabs are thawed and 10-μl aliquots cultured overnight on selective media at 37°c in 5% carbon dioxide. growth of s. pneumoniae, h. influenzae and m. catarrhalis is recorded and confirmed by standard techniques [36, 45] . four isolates each of s. pneumoniae and h. influenzae and two isolates of m. catarrhalis per positive swab are tested for antimicrobial resistance and stored [36, 45] . s. pneumoniae isolates are serotyped using the quellung method (antisera from statens serum institute, copenhagen,denmark). in addition to routine susceptibility testing using the calibrated dichotomous susceptibility disc diffusion method, azithromycin minimum inhibitory concentration (mic) will be determined by etests (ab biodisk, solna, sweden) if the azithromycin disc annulus is <6 mm. for s. pneumoniae, the penicillin mic is determined for penicillin non-susceptible isolates (oxacillin and/or penicillin disc annulus < 6 mm) and for h. influenzae, the ampicillin mic is determined for isolates if the ampicillin disc annulus is < 6 mm. interpretive criteria (clinical and laboratory standards institute breakpoints) used for s. pneumoniae are penicillin non-susceptible mic > 0.12 μg/ml, azithromycin resistance mic ≥ 2 μg/ml; and for h. influenzae, ampicillin resistance mic ≥ 4 μg/ml, azithromycin resistance mic > 4 μg/ml. a nitrocephin-based test will identify beta-lactamase activity in h. influenzae and m. catarrhalis isolates. we will use our previous methods [46, 47] . nucleic acids will be extracted from the media using the high pure viral nucleic acid kit (roche diagnostics, sydney, new south wales, australia), according to the manufacturer's instructions. real-time polymerase chain reaction assays will be used to detect respiratory syncytial viruses (a and b), adenoviruses, influenza viruses (a and b), parainfluenza, human metapneumovirus, human coronaviruses (oc43, hk1, 229e, nl63), enteroviruses, rhinoviruses (and subtypes [48] ) and the more recently described human viruses (human bocavirus 1, parechoviruses, human polyomaviruses k1 and wu) and m. pneumoniae and chlamydia species [49] . serum crp (threshold 5 mg/l) are standard tests that will be analysed locally (diagnostic laboratory of each participating centre). saa, il-6 (threshold < 3 pg/ml), il-10 (threshold < 0.5 pg/ml) and ip-10 (threshold 2.8 pg/ml) will be performed using elisa commercial kits (r&d systems, minneapolis, mn, usa) at our research laboratory. spirometry (in children aged ≥ 5 years) will be performed using american thoracic society criteria and the fev 1 % predicted recorded. we elected not to use oscillatory measures as we found no difference in airway resistance between steady and exacerbation states [33] . thus we will use conventional spirometry although we do not expect to detect significant differences. participation is complete when the child's clinical state returns to baseline and the 'time to next exacerbation' has been obtained. other exit points are if the child is clinically worse prior to day 14 or intolerance to the trial medications requiring withdrawal from the study (as determined by the treating clinician). the primary outcome is the proportion of children whose exacerbations have resolved by day 14. exacerbations will be considered resolved when symptoms and signs are the same as the baseline state. children who are withdrawn from the study or receive additional antibiotic treatment will be categorised as non-resolved. the main secondary outcome is the pc-qol score. other outcomes are the time to next exacerbation; requirement for hospitalisation; duration of exacerbation (persistence of symptoms till 'return to baseline state') and fev 1 % predicted. serum markers (crp, saa, il-6, il-10, ip-10) and data on viruses and respiratory bacterial pathogens, including antibiotic susceptibility patterns to penicillin and azithromycin, will be the secondary laboratory outcomes. we plan to enrol 189 children (63 per arm), providing 84% power (α = 0.0245, two-sided) to detect a halving of the number of children in the active arm achieving resolution by day 14 (that is, azithromycin or amoxicillinclavulanic acid: 60% resolved by day 14, compared with placebo: 30% resolved). this is a conservative estimate when compared with our prospective data of persistent symptoms in 24% of children based on the same diary card [50] . as the primary outcome will be obtained in all enrolled children, a drop-out has not been factored in for the intention-to-treat analysis. with 20% drop-out rate, data from 153 children (51 per arm) for 'per protocol' analysis provides a study power of 75%. both treatment arms are compared with the same placebo arm. while the maximum efficiency is attained by allocating more children to the placebo arm (that is, using an allocation ratio of 1:1:√2), we chose to use a 1:1:1 allocation due to ethical concerns of deviating from standard care in respiratory centres. in the main secondary outcome (pc-qol), based on a between-group difference of 0.9 (minimum important difference [42] ) (sd 0.9), our sample size provides power of 100% (α = 0.05) for data from at least 147 children (that is, assuming at least 80% retention of the 189 children enrolled). for secondary aim 2 (exploring factors that predict response to antibiotics), we will be examining eight main factors and thus a sample size of 147 exceeds the recommended minimum (n = 10 per factor) [51] . the eight factors are smoking, age, underlying aetiology, detection of virus (any versus none, then single versus multiple viruses), presence of azithromycin resistance and blood markers (il-6, il-10, ip-10 levels). data will be reported and presented in accordance with the updated consort criteria [52] . children will be analysed according to allocation status (regardless of subsequent management). an interim analysis is planned and a data safety and monitoring committee will determine if the study should be ceased should superiority of any antibiotic be identified after 50% of sample size is achieved. for our primary aim, the main effects of the interventions will be determined by comparing the primary outcome (resolution of exacerbation) between groups ((azithromycin versus placebo) and (amoxicillin-clavulanic acid versus placebo)). children who exit the study as clinically worse or drop-outs prior to the end point will be considered non-resolved. those who exit the study as 'returned to baseline' will be considered resolved. odds ratios will be calculated and, if appropriate, number needed to treat (for benefit) will be expressed. tests of a treatment arm versus placebo at the end of the study for the primary outcome will be performed at the 2.45% significance level to account for spending some alpha at the interim analysis. per protocol analysis will be an a priori secondary analysis. for clinical secondary outcomes (secondary aim 1), t-tests or mann-whitney will be used for continuous variables (according to normality of data distribution). a kaplan-meier curve will be constructed for each group for 'time to resolution' and 'time to next exacerbation' as done previously [53] . for secondary aim 2 (factors that predict response to antibiotics), univariate analysis will be used to examine the biological factors listed above. factors that have a p-value < 0.2 will be included in a logistic regression model. potential interactions (for example, virus with bacteria) will be examined in the model. descriptive data will be used for secondary aim 3 (point prevalence of respiratory pathogens). a data safety monitoring committee has been established and has met prior to commencement of this study. it was determined that, when 50% of the sample size has been achieved, the stopping rules are as detailed below. if superiority between each antibiotic arm and the placebo arm is shown at significance level of 0.001, the study will cease. if superiority of only one antibiotic is shown, we will continue recruiting children to the other antibiotic arm and to the placebo arm but not to the superior antibiotic arm. if the serious adverse events (related to the medications) in each antibiotic arm outnumber the adverse events in the placebo arm at significance level of 0.01 or less, the study will cease. if increased adverse events of only one antibiotic is shown, we will continue recruiting children to the other antibiotic arm and to the placebo arm but not to the antibiotic arm related with increased adverse events. however, the study is not powered to detect between-group differences in total adverse events. the protocol has received ethical approval from the re despite the considerable global burden, bronchiectasis services receive disproportionately fewer allocated resources (clinical and research) when compared with other chronic respiratory diseases [3, 54, 55] . the marked paucity of rcts [21, 55] is reflected in the existence of only a single (small) published placebo-controlled rct in children with bronchiectasis [21, 56] . that study described a reduction in sputum purulence and airway hyper-responsiveness in children receiving roxithromycin (n = 13) [57] . there are no rcts on the management of bronchiectasis exacerbations in children [58] . almost all current recommendations are based on cf management [21, 28] . such extrapolation can, on occasions, be detrimental for those with non-cf bronchiectasis. for example, a large rct found that deoxyribonuclease (efficacious for cf) increased exacerbations and decline in fev 1 in adults with bronchiectasis [59] despite prior case reports advocating its use [60] . the importance of exacerbations in most chronic respiratory diseases is generally accepted. unfortunately, data on triggers, definitions and effective treatment of bronchiectasis exacerbations in both children and adults are scarce [56, 61, 62] . although viral triggers of acute exacerbations are well described in asthma [46] and copd [63, 64] , no such data exist for bronchiectasis. whether other potential respiratory pathogens (m. pneumoniae and chlamydia species) trigger exacerbations has never been examined. our retrospective study found that 34% of exacerbations were preceded by a viral-like illness [29] . thus, for the first time in this population, we will determine the nature and diversity of respiratory viruses m. pneumoniae and chlamydia species associated with bronchiectasis exacerbations. our study addresses a large knowledge gap in an under-researched area [55] . if the intervention is successful, it would lead to improved short-term (and possibly long-term) health benefits. conclusive results would produce changes to evidence-based standard treatment guidelines. in our retrospective data of 115 respiratory exacerbations [29] , we found that 35% of exacerbations failed to respond to oral antibiotic therapy (duration could not be determined) and required hospital admission. in our prospective cohort of 69 children followed for 900 childmonths (156 exacerbations), 36 exacerbations (23%) were treated with intravenous antibiotics following persistence of symptoms, that is, non-resolution of the exacerbation episode. generally, hospitalisation began three to five weeks following the initiation of oral antibiotics and 'return to baseline' occurred within two weeks of hospitalisation. based on our data that 24% of otherwise well children in the community still have a cough associated with a viral infection at day 14 [50] , we chose day 14 as the time point for this rct. we also asked parents and clinicians about their willingness to use placebo for a period of time; 14 days was the limit with a safety exit point at day 7. adult bronchiectasis studies show that qol measures, particularly cough-specific qol, are valid and important outcome measures [62, 65] . likewise, we have shown the utility of a paediatric chronic cough qol (the pc-qol) score in children with bronchiectasis [66] . in summary, our double-blind, double-dummy rct that examines the superiority of azithromycin and amoxicillin-clavulanic acid (compared with placebo) for exacerbations of bronchiectasis in children has the 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questionnaire for pediatric chronic cough (pc-qol) nasopharyngeal versus oropharyngeal sampling for detection of pneumococcal carriage in adults streptococcus pneumoniae and noncapsular haemophilus influenzae nasal carriage and hand contamination in children: a comparison of two populations at risk of otitis media random colony selection versus colony morphology for detection of multiple pneumococcal serotypes in nasopharyngeal swabs newly identified respiratory viruses in children with asthma exacerbation not requiring admission into hospital a sensitive, specific, and cost-effective multiplex reverse transcriptase-pcr assay for the detection of seven common respiratory viruses in respiratory samples distinguishing molecular features and clinical characteristics of a putative new rhinovirus species, human rhinovirus c (hrv c) molecular diagnosis of medical viruses asthma and protracted bronchitis: who fares better during an acute respiratory infection? relation between several variables consort 2010 statement: updated guidelines for reporting parallel group randomised trials zinc and vitamin-a supplementation in indigenous children hospitalised with episodes of lower respiratory tract infection: a randomised controlled trial bronchiectasis: a neglected cause of respiratory morbidity and mortality clinical challenges in managing bronchiectasis non-cystic fibrosis bronchiectasis exacerbations effect of roxithromycin on airway responsiveness in children with bronchiectasis: a double-blind, placebo-controlled study short courses of antibiotics for children and adults with bronchiectasis rhdnase study group: treatment of idiopathic bronchiectasis with aerosolized recombinant human dnase i clinical benefit from nebulized human recombinant dnase in kartagener's syndrome procalcitonin in stable and unstable patients with bronchiectasis quality of life and inflammation in exacerbations of bronchiectasis role of viral infections in asthma and chronic obstructive pulmonary disease identifying viral infections in vaccinated chronic obstructive pulmonary disease (copd) patients using clinical features and inflammatory markers assessing response to treatment of exacerbations of bronchiectasis in adults the burden of disease in pediatric non-cystic fibrosis bronchiectasis submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution we thank the research staff (lesley versteegh, clare wilson, sophie anderson-james, joanne tuppin, stacey spencer, carol willis) for facilitating the study, robert ware for generating the randomisation sequences and anita champion for allocating the children and dispensing the medications. we are also grateful to members of the indigenous reference group of the child health division at menzies for supporting this study and for overseeing the cultural aspects. we also thank professor alan isles, professor craig mellis and associate professor chris blyth for voluntarily providing their time in their participation as members of the data safety monitoring committee. the authors declare that they have no competing interests.authors' contributions ac conceived the study, and participated in its design and coordination and drafted the manuscript. pm, cr, kg, pva, aw, ko, pt and ts participated in its design and submission to the national health and medical research council. eb and gm participated in initiating the project and imm in the viral analysis plan. ibm, cb and hb will assist in recruitment and assessment of the children. mdc advised on statistical issues. all authors read and approved the final manuscript.authors' information abc, cfr, acw, ppva, cab, ibm and hmb are paediatric respiratory physicians, kg is a paediatric infectious disease physician, pjt is an adult respiratory physician, kfo is an epidemiologist, tps and imm are virologists, mdc is a statistician, ejb and gbm are research nurses and pm is a general paediatrician. key: cord-032926-mrnsaexq authors: waitz, markus; engel, corinna; schloesser, rolf; rochwalsky, ulrich; meyer, sascha; zemlin, michael; bohnhorst, bettina; peter, corinna; hoppenz, marc; pabst, thomas; zimmer, klaus-peter; franz, axel r.; ehrhardt, harald; schmidt, annesuse; larsen, alexander; hoffmann, paul; haertel, christoph; frieauff, eric; sandkötter, julia; masjosthusmann, katja; deindl, philipp; singer, dominique title: application of two different nasal cpap levels for the treatment of respiratory distress syndrome in preterm infants—“the opttimmal-trial”—optimizing peep to the immature lungs: study protocol of a randomized controlled trial date: 2020-10-01 journal: trials doi: 10.1186/s13063-020-04660-0 sha: doc_id: 32926 cord_uid: mrnsaexq background: nasal continuous positive airway pressure (cpap) applies positive end-expiratory pressure (peep) and has been shown to reduce the need for intubation and invasive mechanical ventilation in very low birth weight infants with respiratory distress syndrome. however, cpap failure rates of 50% are reported in large randomized controlled trials. a possible explanation for these failure rates is the application of insufficient low levels of peep during nasal cpap treatment to maintain adequate functional residual capacity shortly after birth. the optimum peep level to treat symptoms of respiratory distress in very low birth weight infants has not been assessed in clinical studies. the aim of the study is to compare two different peep levels during nasal cpap treatment in preterm infants. methods: in this randomized multicenter trial, 216 preterm infants born at 26 + 0–29 + 6 gestational weeks will be allocated to receive a higher (6–8 cmh(2)o) or a lower (3–5 cmh(2)o) peep during neonatal resuscitation and the first 120 h of life. the peep level within each group will be titrated throughout the intervention based on the fio(2) (fraction of inspired oxygen concentration) requirements to keep oxygenation within the target range. the primary outcome is defined as the need for intubation and mechanical ventilation for > 1 h or being not ventilated but reaching one of the two pre-defined cpap failure criteria (fio(2) > 0.5 for > 1 h or pco(2) ≥ 70 mmhg in two consecutive blood gas analyses at least 2 h apart). discussion: based on available data from the literature, the optimum level of peep that most effectively treats respiratory distress syndrome in preterm infants is unknown, since the majority of large clinical trials applied a wide range of peep levels (4–8 cmh(2)o). the rationale for our study hypothesis is that the early application of a higher peep level will more effectively counteract the collapsing properties of the immature and surfactant-deficient lungs and that the level of inspired oxygen may serve as a surrogate marker to guide peep titration. finding the optimum noninvasive continuous distending pressure during early nasal cpap is required to improve cpap efficacy and as a consequence to reduce the exposure to ventilator-induced lung injury and the incidence of chronic lung disease in this vulnerable population of very preterm infants. trial registration: drks.de drks00019940. registered on march 13, 2020 very low birth weight infants (vlbwi) with surfactant deficient lungs frequently develop respiratory distress syndrome (rds) with the need of early respiratory support in the delivery room and during the active phase of rds (i.e., first 5 days of life) [1] . the use of nasal cpap to avoid intubation and the consecutive detrimental effects of invasive mechanical ventilation to the immature lungs has been shown to reduce the rate of bronchopulmonary dysplasia (bpd) and death in meta-analyses [2] . the diagnosis of bpd is associated with lifelong impaired lung function and negatively affects the neurodevelopmental outcome in this high risk group of infants [3] . nasal cpap in the delivery room is now the recommended primary respiratory support in preterm infants with rds. results of large randomized controlled trials comparing early nasal cpap versus primary intubation found that approximately 46.0-51.2% of infants can be saved from intubation with this approach [4, 5] . however, almost half of the infants in the large cpap trials failed on cpap, which ultimately resulted in exposure to some degree of invasive mechanical ventilation and may explain limited effects on the reduction of the incidence of bpd [1, 6, 7] . application of early nasal cpap aims to recruit the lungs and maintain functional residual capacity (frc). the degree of lung recruitment is influenced by the level of peep applied to the immature lung [8] . expert panels from international societies currently recommend a peep level of 5-6 cmh 2 o [4, 9] . however, as the authors state, evidence for these recommendations is very limited. no clinical studies specifically assessed the effect of different peep levels during the active phase of rds in preterm infants on outcomes such as the need for invasive mechanical ventilation and other neonatal morbidities (i.e., bpd). results of a secondary analysis from a cohort study in 34 international centers that participated in a nasal intermittent positive pressure ventilation trial indicate a large variation of peep levels used in clinical practice during neonatal resuscitation and the first 28 days of life (i.e., 3-9 cmh 2 o) [10] . only one clinical trial with a small sample size, including preterm infants beyond the active phase of rds, randomized subjects to receive a higher or a lower level of peep after extubation (4-6 cmh 2 o versus 7-9 cmh 2 o) and found a significantly lower rate of reintubation in the higher peep group [11] . results from animal studies further suggest that using higher peep levels (8-12 cmh 2 o) improves gas exchange and avoids lung collapse when compared to lower levels of peep [12, 13] . the optimum level of peep during nasal cpap that effectively maintains frc and avoids mechanical ventilation in preterm infants with rds is unknown and remains to be determined. the proposed randomized controlled trial was designed and powered to compare the effect of two different peep levels during nasal cpap (6-8 cmh 2 o versus 3-5 cmh 2 o) in preterm infants in the first 120 h of life on the need for intubation and the incidence of pre-defined cpap failure criteria. the primary hypothesis of this study is that the use of a higher peep range in preterm infants born at 26 + 0-29 + 6 weeks gestational age (ga) receiving prophylactic nasal cpap support after birth reduces the incidence of intubation and/or meeting predefined cpap failure criteria within the first 120 h of life when compared to the application of a lower peep range. this will be an unblinded multicenter randomized controlled parallel group comparison of two different peep ranges during nasal cpap support in the first 120 h of life. inclusion criteria ga at birth 26 + 0/7 to 29 + 6/7 weeks severe congenital anomalies affecting breathing control (cerebral anomalies, chromosomal anomalies, prenatally diagnosed intracranial hemorrhage) or gas exchange (pulmonary hypoplasia due to congenital diaphragmatic hernia or oligo/ anhydramnios present at < 22 weeks ga or other pulmonary or intrathoracic malformations, etc.) or hemodynamics (cyanotic heart disease, ductal dependent systemic perfusion, or similar) decision not to provide full life support/decision for palliative care only before study entry parents not able to understand the study due to language barriers who will take informed consent? {26a} all pregnant women who are admitted to the local prenatal/maternity wards with threatening preterm delivery before 29 + 6/7 weeks should be approached. both parents will be asked for consent for their baby to participate in the study given that it will be delivered between 26 + 0 and 29 + 6 weeks of gestation. informed consent will be taken by good clinical practice (gcp) qualified staff members. to date, no sampling of biological material is planned during the study. since the optimum level of peep to treat rds is unknown, we decided to choose the levels of peep within the reported peep levels used in clinical practice from large surveillance data (3-9 cmh 2 o) and within the limits of current treatment guidelines [4, 9, 10] . to allow for effective discrimination between the two treatment groups, we decided that the difference of the applied level of peep in the delivery room must be exactly 3 cmh 2 o. at last, the choice of the defined peep levels yielded the highest agreement in the prestudy meetings of all participating centers. the study intervention is the application of early nasal cpap/nasal intermittent positive pressure ventilation (nippv) with higher peep range (6-8 cmh 2 o, intervention group) compared to a lower peep range (3-5 cmh 2 o, control group) in the first 120 h of life. the intervention starts immediately after birth with the first application of nasal cpap/nippv in the delivery room. the study intervention ends at a postnatal age of 120 h. randomized subjects will receive nasal cpap/ nippv immediately after birth using a short nasopharyngeal tube, face mask, or binasal prongs (center specific). the peep level will be set within the allocated peep range: peep low (3-5 cmh 2 o) or peep high (6-8 cmh 2 o). during resuscitation, the initial peep setting in the intervention group must be set 3 cmh 2 o higher than in the control group and will be determined by center guideline prior to study start. the initial peep will be maintained during the delivery room management and will not be adjusted. application of peep in the delivery room will be provided by a t-piece resuscitator or a conventional ventilator. the use of a self or flow-inflating bag is not permitted for initial respiratory support. subjects will be further resuscitated according to the european consensus guidelines [4] . sustained inflation maneuvers can be applied according to local policies for initial stabilization. primary nasal nippv (synchronized or not) can be used in the delivery room. after admission to the neonatal intensive care unit, the peep level will be adjusted according to the level of inspired oxygen required to meet the centerspecific study spo 2 target range within the maximum range of 85-95% throughout the interventional period using the following peep titration protocol: (peep adjustments should be made on a half-hourly basis to allow the assessment of effects). prior to study initiation, we strongly recommend local guidelines for intubation and mechanical ventilation be defined, as well as the indication criteria for surfactant administration that have to be applied equally within both peep groups. suggested intubation criteria within the study are: fio 2 ≥ 0.5 for > 1 h and/or pco 2 ≥ 70 mmhg in two consecutive blood gas analysis > 2 h apart after the application of a maximum of 2 surfactant doses (either insure (intubate surfactant extubate) or less invasive, i.e., lisa). if a study subject requires intubation, decisions on the mode of invasive ventilation, weaning strategies, and extubation are at the discretion of the responsible medical team of the study site with settings and modes identical for both treatment groups. after extubation, the peep will be set and adjusted according to the initially assigned peep range during nasal cpap/nippv. after the study intervention period, the medical team at each study site will decide on the further mode of respiratory support and weaning strategies. in both treatment groups, fio 2 , set peep levels, and pressures during cpap and nippv (mean airway pressure, peak inspiratory pressure, inspiratory time) will be recorded every hour throughout the interventional period on a worksheet and has to be signed by a study physician. all data will be transferred from hardcopy to electronic crf files and are stored within the database of the center for pediatric clinical studies (cpcs), university of tuebingen. this database fulfills all gcp and fda cfr part 11 requirements. after termination of the study, all datasets are backed up within a locked area at the justus-liebig-university of giessen and at the eberhard-karls-university of tuebingen for at least 10 years after the end of the study. individual preterm end of study intervention for the individual patient treatment may be terminated for safety concerns by the attending physician together with the local principal investigator or according to the wish of the patient's parents or legal representatives at any time. the reasons for premature termination of the study intervention have to be documented in the study database. these patients will be maintained in the study, study visits have to be done as planned, and their outcome will be included in the intention-to-treat analysis. for a study center a study center not following the protocol or failing to recruit patients may be closed prematurely. all infants already recruited at that center will be maintained in the study, study visits have to be done as planned, and their outcome will be included in the intention-to-treat analysis. for the whole study for safety: all potential complications related to the intervention occurring during the care of an infant enrolled in this trial have to be reported immediately to the coordinating investigator according to ich-gcp guidelines and national and european regulations. furthermore, information on all prematurity-associated complications is collected in the study database. these will include safety reports after 50, 100, and 150 completely documented patients to the data monitoring committee (dmc), who will continuously keep track of the incidence of such events in both study groups. the trial will be stopped by the coordinating investigator on the advice of the dmc, if the riskbenefit ratio of the study intervention (i.e., application of higher peep ranges) is significantly changed based on new published data becoming available. the trial will also be stopped temporarily or permanently in case that safety outcomes (i.e., mortality or major diseases of prematurity) occur more frequently in the treatment group or if complications directly related to the study intervention (e.g., adverse events directly attributable to device failures) require a change in the risk-benefit assessment. local principal investigators and team members are required to participate in a pre-study meeting where details of study protocol, data collection, the application, and adjustments of peep will be discussed. all participating centers will receive detailed written instructions. in cases of uncertainty, it will be possible to contact the center for pediatric clinical studies (cpcs, university of tuebingen) at any time. management with alternative noninvasive respiratory support (i.e., nippv) nippv is frequently used as primary mode of noninvasive ventilation in the delivery room and the first days of life. because the settings during nippv affect the applied mean airway pressure and gas exchange, nippv settings and weaning during the study intervention must be equally used in terms of inspiratory times, respiratory rate, and peak inspiratory pressures, which will be monitored and documented during the study intervention. we strongly recommend a center-specific protocol for the use of nippv prior to study initiation. randomized infants will receive a loading dose of caffeine citrate of (10)-20 mg/kg and a maintenance dose of (5)-10 mg/kg/days. up to 20 mg/kg/days is permitted to prevent intubation due to apnea of prematurity. because the optimal dose of caffeine has not yet been established, exact dosing will be left to the standards of the participating centers-but centers will need to have a written dosing scheme. furthermore, caffeine treatment will be monitored throughout the study to detect any bias in caffeine use early. patients that are enrolled into the study are covered by patient insurance (hdi global se). the primary outcome is meeting one of the following treatment failure criteria within the first 120 h after birth: the description of the study procedures and examinations are shown in fig. 1 . a summary of important outcomes and time points of assessment are shown in table 1 . a detailed description of the study process for the individual patient is summarized in fig. 2 . based on a pre-study survey among participating centers and the results of the amv study [14] , we expect 50% primary endpoints within the control group (lower peep level). the intervention will be regarded as being successful if it lowers the rate of the primary endpoints to 30%. this follows the expectations within similar studies [15] . to lower the rate of primary endpoints from 50 to 30% and to confirm this via cochran-mantel-haenszel test (level of significance = 0.05, power = 80%), a sample size of 103 patients per group will be needed. to account for 5% drop outs, an overall sample size of 216 patients have to be recruited and treated within the study. patients will be recruited in 6 german tertiary care neonatal centers. results of a systematic surveillance protocol prior to study start yielded a number of 240 eligible preterm infants meeting the inclusion criteria annually in all participating centers. based on the assumption that approximately 50% of eligible infants will be included in the study, the recruitment period is expected to be 27 months. all preterm infants who are born at the participating institutions with a gestational age at birth of 26 + 0/7 to 29 + 6/7 weeks have to be screened for the study. each screened patient is given a patient screening number (psn) in consecutive order according to the screening log in the investigator site file (isf). this number is the overall identifier of the pseudonymized patient throughout the study. for every screened patient, a screening form has to be filled in the electronic case report form (ecrf). this enables the documentation of non-biased recruitment. the screening ecrf form will document presence and absence of inclusion and exclusion criteria, whether the parents had been approached and whether informed consent was given, but will not document any patient identifiers. outborn infants will not be screened as study treatment has to start immediately after birth. patients can only be enrolled into the study if informed written consent was given by both parents/guardians (by the only parent/guardian in case of single-parent/guardian families) before birth. in case parents are less than 18 years of age, the relevant legal guardian(s) of the child has/have to sign the informed fig. 1 overview about the study procedures and examinations. ic, informed consent; cus, cerebral ultrasound; mri, magnetic resonance imaging; pma, postmenstrual age consent. following multiple birth, parents are asked whether the infants could be randomized separately. if parents wish randomization to one study arm, the second child is treated like the randomized child, but not recruited to the study. the parental wish is documented on the informed consent form. randomization and allocation concealment infants will be randomly assigned in a 1:1 ratio with variable block sizes. randomization lists will be stratified by center and gestational age (26 + 0-27 + 6 and 28 + 029 + 6 weeks). sequentially numbered, sealed, opaque envelopes indicating the study group will be prepared. provision of randomization envelopes will be done by an independent institution not involved in patient recruitment. please see the "sequence generation {16a}" section. please see the "sequence generation {16a}"section. who will be blinded {17a} blinding of doctors, nurses, and parents for the intervention is not possible in this study. please see the "who will be blinded {17a}" section. data management plan, quality assurance, and monitoring a data management plan will be written describing the whole flow of the study data. documentation of study data will be done by the local principal investigator via ecrf within a web-based study database. source data will remain within the study sites. quality and correctness of the study data will be ascertained by gcpconform monitoring of the study. monitoring will be done on a risk-adapted basis and will include remote and on-site monitoring of the data by trained monitors. please see the "study procedures, examination methods, and outcome assessment" section. please see the "data management plan, quality assurance, and monitoring" section. plans for collection, laboratory evaluation, and storage of biological specimens for genetic or molecular analysis in this trial/future use {33} to date, no sampling of biological material is planned during the study. the following analysis populations are defined within this study: consists of all patients included into the study of whom written parental consent was obtained and not withdrawn. the safety population is identical to the intention to treat population and consists also of all patients included into the study of whom written parental consent was obtained and not withdrawn. patients fulfilling at least one of the following criteria will be excluded from the per protocolpopulation: peep level is not documented or not between 3 and 5 cmh 2 o-if the infant is in the low peep group-or 6-8 cmh 2 o-if it is randomized in the high peep group-for more than 10% of time during the intervention period. intubation within the first 10 min after birth and invasive mechanical ventilation for more than 1 h. the analysis of the primary endpoint will be done by cochran-mantel-haenszel test stratified for treatment groups. the primary endpoint will be re-evaluated by cochran-mantel-haenszel test adjusted for gestational age group (26 + 0-27 + 6 versus 28 + 0-29 + 6 weeks) and center. if the final number of centers does not allow adjustment for single centers, centers will be grouped. the grouping of centers will be justified within the statistical analysis plan. all secondary endpoints will be compared by cochran-mantel-haenszel test or student's t test. in case of non-normally distributed data, student's t test will be replaced by wilcoxon-mann-whitney test. the distribution of severity of bpd will be compared between the treatment groups by generalized logit model. clinical and demographic characteristics of maternal and neonatal data will be described by mean and standard deviation, median, quartiles and minimum/ maximum or rate and percentage. the analysis of the follow-up endpoints will be specified in an amendment to the study protocol before start of the 2-and 5-year follow-up. in case of more than 10% missing values concerning the primary endpoint, a worst case/best case analysis for this endpoint will be performed in the intention to treat population as sensitivity analyses and results will be included into the final report. no sensitivity analyses will be done for secondary or further relevant endpoints. in case of more than 20% missing values concerning one of the endpoints until pma36, this endpoint will only be tabulated but no statistical test will be performed due to risk of biased data. all analyses will be predefined in a statistical analysis plan written before end of study and completion of data monitoring. only the analysis of the primary outcome variable in the intention-to-treat population will be considered confirmatory on a level of significance of 0.05. all other analyses including the analysis of the primary outcome variable in the per protocol population and all analyses concerning secondary endpoints will be considered exploratory only. not planned there are no subgroup analyses predefined within the study protocol. if appropriate, they will be defined within the statistical analyses plan. please see the "statistical analysis {20a}" section. plans to give access to the full protocol, participant leveldata, and statistical code {31c} access to the full study protocol and the final statistical analysis plan will be given upon request. there is no plan to give access to participant-level data for data protection reasons. composition of the coordinating center and trial steering committee {5d} please see the "composition of the data monitoring committee, its role and reporting structure {21a}" section. the dmc is represented by two neonatologists independent from the sponsor or competing interests. the dmc will be contacted by the two coordinating investigators (harald ehrhardt and markus waitz) based on their expertise (being at least principal investigators in clinical trials for more than 5 years in the past and experts in the field of neonatology). details (name and contact information) of the composition of the dmc are provided in the study protocol or upon request. safety aspects will be documented continuously throughout the study including the categories expected serious adverse events (esae) and unexpected serious adverse events (usae) events and will be reported within safety reports to the dmc. safety analyses will be done after 50, 100, and 150 included patients have reached pma 36 weeks. reports of these data will be sent to the dmc members by the responsible biometrician (cpcs, university of tuebingen). based on the reported data, the dmc will provide recommendations on continuation of the trial and will report its decision to the coordinating investigators. the following expected serious (esae) and unexpected serious (usae) adverse events known to occur in this population of very preterm infants will be reported to the dmc as rates and percent, stratified for treatment group. all other adverse events meeting the following criteria of seriousness will be considered unexpected serious adverse events and must be documented in the ae-from of the ecrf. usae (any adverse event that resulted in any of the following): death serious deterioration in the health of the subject that resulted in any of the following: -life-threatening illness or injury, -permanent impairment of a body structure or a body function, -medical or surgical intervention to prevent lifethreatening illness or injury or permanent impairment to a body structure or a body function. to ensure that there is no higher risk of deaths caused by the intervention, this will be evaluated with the help of 95% confidence limits that will be presented for both treatment groups. a dmc manual will describe the details of the safety analysis and has to be approved by all dmc members before preparing the first dmc report. monitoring for this study is provided by the center for pediatric clinical studies (cpcs) of the university hospital tuebingen. central monitoring of the ecrf will also be provided by the cpcs, certified by iso9001. monitoring is employed primarily for the subjects' safety, as well as for quality assurance of medical procedures. the centers will be visited by the monitor on a regular basis. in accordance with the laws on data protection, the investigator's files, data collection forms, and original documents have to be made available to the monitor. the investigators will discuss the course of the study with the monitor in an appropriate manner. trial institutions, facilities, laboratories, and all data (including raw data and ecrfs) must always be available for inspection by an authority. plans for communicating important protocol amendments to relevant parties (e.g., trial participants, ethical committees) {25} any additions and changes made to the protocol have to be submitted to the responsible ethics committees for review. changes to protocol procedures (amendments) require a specification of reasons and must be signed by an authorized person for the respective protocol; the amendments are then considered part of the protocol. substantial changes, in particular with regard to patients' health interests, require a new decision from the appropriate ethics committees. the final report for the study will be compiled by the coordinating investigators within a period of 360 days upon completion of the study and forwarded to the ethics committees. furthermore, the coordinating investigators will submit the final report for publication as soon as possible. nasal cpap application with selective surfactant administration is currently the primary and recommended respiratory support in very low birth weight infants with developing or active rds [1, 4] . cpap has been proven to be at least as effective as primary intubation in the delivery room with regard to the outcome of bpd and significantly reduced the need for invasive mechanical ventilation in large randomized controlled trials [1, 6, 7] . however, reported cpap failure rates in these trials are still high (46.0-51.2%) and cpap failure was ultimately linked with the exposure to mechanical ventilation, an intervention clearly associated with the diagnosis of bpd [5, 14, 16] . peep levels used in these trials ranged from 4 to 8 cmh 2 o. the evidence for the decision to apply these specific peep levels of 4-8 cmh 2 o in very immature preterm infants is low but considered to be safe. from a pathophysiological perspective, early application of peep to the surfactant deficient lungs counteracts the collapsing properties, maintains frc, and supports lung liquid clearance immediately after birth [17] . in an attempt to accelerate lung liquid clearance, sustained increases of continuous positive airway pressure (i.e., sustained lung inflation maneuvers (sli)) have been proposed to effectively recruit gas exchange units after birth [18] . while this sli strategy has been shown to reduce the need for intubation within the first 72 h of life in vlbwi, the results of the sail trial showed no difference in the rate of bpd, but an increased mortality in the sli group discouraging the use of this aggressive recruitment technique [18, 19] . effective lung liquid clearance is necessary to allow gas exchange, but the approach of sli does not take into account the fact that interstitial liquid tends to re-accumulate in the pulmonary tissue over a longer period of time [20] . in addition, rds caused by primary surfactant deficiency of the premature lungs predisposes atelectasis and consecutive impaired gas exchange. it is considered a longer lasting dynamic disease process and therefore may require prolonged and sufficient peep support [21] . early surfactant treatment, in the recent years predominantly administered via less invasive application procedures or the insure technique in the neonatal population, further reduced the need of invasive ventilation, but unfortunately did not yield the desired reduction in the incidence of bpd in multicenter studies [7, 14] . stepwise recruitment strategies (in-rec-sur-e -intubate recruit surfactant extubate) using invasive high frequency oscillatory ventilation, where fio 2 serves as surrogate marker of effective lung inflation, combined with surfactant administration are currently under investigation and have been shown to reduce oxygen requirements and the incidence of bpd in one randomized controlled trial and retrospective studies [15, 22, 23] . sli maneuvers and the inrecsure procedures aim to apply higher pressures over a short period of time indicating that the immature preterm lung may require higher continuous distending pressures than expected in the past. however, clinical trials assessing the application of early, prolonged and higher levels of non-invasive peep to avoid collapse of the neonatal lung during nasal cpap are not available but may be an alternative or adjunctant to the abovementioned ventilation and treatment strategies. the hypothesis that early application of "higher" peep levels could be beneficial is supported by animal data where higher peep levels (8-12 cmh 2 o) were more effective than lower levels in terms of gas exchange [12, 13] . more recently, a dynamic increase of peep in preterm lambs (up to 14-20 cmh 2 o for 3 min) improved response to surfactant treatment and created a more uniform lung aeration, compared to positive pressure ventilation or sli maneuvers [24] . further evidence that higher pressure levels may decrease the need for invasive mechanical ventilation derives from studies using nippv as a mode of non-invasive respiratory support. this ventilation strategy augments cpap by superimposing positive pressure inflation at different respiratory rates, imitating time-cycled pressure-controlled ventilation. results of the actual meta-analyses showed a reduction of the need for intubation and reintubation compared to nasal cpap when nippv was used as primary mode of ventilation or post extubation [25, 26] . it is unclear how nippv mediates its clinical benefits, but one possible explanation could be the increase in mean airway pressure during nippv [27] . concerns that may have discouraged the further assessment of higher levels of peep in the neonatal population might derive from results of the coin trial where infants in the cpap group had a higher rate of pneumothoraces with the use of a peep of 8 cmh 2 o [1] . this association, however, has to be interpreted with caution. as the authors stated, the median cpap level was 8 cmh 2 o for infants who developed a pneumothorax as well as for those in whom a pneumothorax did not occur. if the cpap pressure would have been the cause for the development of pneumothorax, it is interesting that the incidence of air leaks was lower in the intubation group, where infants were exposed to higher peak and mean airway pressures as compared to the cpap group. a more reasonable explanation of these findings might be the lower rate of infants treated with surfactant in the cpap-group and the high fio 2 intervention threshold for intubation and surfactant administration (fio 2 > 0.6), since surfactant treatment has been proven to reduce the incidence of air leaks in preterm infants [21] . the support and curpap study with a similar study design and similar peep levels of 5-8 cmh 2 o did not find any difference in the incidence of air leaks, but had a lower threshold (i.e., fio 2 > 0.4) for surfactant administration [6, 7] . to our surprise, no clinical trial since the introduction of nasal cpap was conducted that assessed the efficacy of different peep levels during nasal cpap treatment for rds in the preterm population. given the facts that the available strategies to avoid mechanical ventilation did not (yet) result in a reduction of bpd and are still associated with high treatment failure rates and that other promising strategies (i.e., cell based therapies) have to be critically evaluated before introduction into clinical practice, it seems conclusive to improve the effectiveness of the well-established cpap therapy as the currently accepted gold standard of noninvasive respiratory support in vlbwi [28, 29] . our hypothesis is that the early application of a higher (6-8 cmh 2 o) versus a lower (3-5 cmh 2 o) peep range will more effectively recruit and maintain lung volumes in preterm infants with ga 26 + 0-29 + 6 weeks during the first 120 h of life and further reduce the need for mechanical ventilation and respiratory failure. to avoid exposure to unnecessary high continuous distending pressures, we further decided to follow the approach of titrating the level of peep within the randomized range according to the fraction of inspired oxygen to maintain arterial oxygen saturation in the target spo 2 range. there are potential limitations in our study design that we addressed in the pre-study meetings: (1) all participating centers use nasal cpap and nippv as primary respiratory support and post extubation. because settings (inspiratory time, peak inspiratory pressure and respiratory rate) during nippv significantly affect the applied mean airway pressure and gas exchange, this could potentially result in unexpected and undesired differences in the study outcomes if this strategy is used unevenly between the two treatment groups. to resolve this issue, we decided that settings and weaning during the study intervention must be equally applied to both treatment arms in terms of inspiratory times, respiratory rate, and peak inspiratory pressures, which will be monitored and documented during the study intervention. the preparation of a center-specific protocol for the use of nippv prior to study initiation is strongly recommended and communicated during the pre-study meeting. (2) analysis of the pre-study surveillance protocol revealed that participating centers use different modes of surfactant administration (insure or less invasive surfactant administration) as well as different thresholds and indications (fio 2, pco 2 , work of breathing) for surfactant administration. however, participating centers follow local guidelines ensuring that the indications and the mode of surfactant application are used similar between the two study groups within each center. (3) one of the primary endpoints is defined as need for intubation and invasive mechanical ventilation > 1 h. although we strongly recommend that infants should be intubated if fio 2 ≥ 0.5 for > 1 h and/or pco 2 ≥ 70 mmhg in two consecutive blood gas analysis > 2 h apart after the application of a maximum of 2 surfactant doses, some physicians may however withheld intubation for any reasons. therefore, we have chosen the criteria fio 2 ≥ 0.5 for > 1 h and/or pco 2 ≥ 70 mmhg in two consecutive blood gas analysis > 2 h apart after the application of a maximum of 2 surfactant doses as fulfillment of the primary endpoint as well (treatment failure). the abovementioned indicators for intubation (fio 2 , pco 2 ) will be documented on an hourly basis. (4) some physicians may have reservations against very high or very low peep settings that may lead to protocol violations. during the study preparation process and the pre-study meetings, there was a high agreement between the participating centers for the use of the two defined peep ranges. the ventilator parameters peep and fio 2 are recorded on an hourly basis to confirm protocol compliance or detect violence regarding the intended peep settings, which will then be discussed with the study monitor and the responsible investigator at the study site as soon as possible. the start of recruitment is expected to be may 01, 2020. the estimated date of completed recruitment is july 31, 2022. the protocol version number is 1.2. the date of the protocol version is december 04, 2019. division of neonatology division of pediatric pulmonology neonatology and pediatric intensive care medicine, hospital cologne 10 department of general pediatrics, university children's hospital muenster, albert-schweitzer-campus 1, 48149 muenster, germany. 11 division of neonatology and pediatric intensive care nasal cpap or intubation at birth for very preterm infants noninvasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis validation of the national institutes of health consensus definition of bronchopulmonary dysplasia european consensus guidelines on the management of respiratory distress syndrome -2019 update noninvasive ventilation in neonatology early cpap versus surfactant in extremely preterm infants randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates effects of nasal continuous positive airway pressure (ncpap) on breathing pattern in spontaneously breathing premature newborn infants european resuscitation council guidelines for resuscitation resuscitation and support of transition of babies at birth resuscitation variation in positive end-expiratory pressure levels for mechanically ventilated extremely low birth weight infants a randomized controlled trial of two nasal continuous positive airway pressure levels after extubation in preterm infants surfactant and physiologic responses of preterm lambs to continuous positive airway pressure positive end expiratory pressure during resuscitation of premature lambs rapidly improves blood gases without adversely affecting arterial pressure avoidance of mechanical ventilation by surfactant treatment of spontaneously breathing preterm infants (amv): an open-label, randomised, controlled trial efficacy of a new technique -intubate-recruit-surfactant-extubate -"in-rec-sur-e" -in preterm neonates with respiratory distress syndrome: study protocol for a randomized controlled trial nasal continuous positive airway pressure (cpap) for the respiratory care of the newborn infant sustained inflation versus positive pressure ventilation at birth: a systematic review and meta-analysis effect of sustained inflations vs intermittent positive pressure ventilation on bronchopulmonary dysplasia or death among extremely preterm infants: the sail randomized clinical trial pulmonary interstitial pressure in anesthetized paralyzed newborn rabbits the use of surfactants in 2009 high-frequency oscillatory ventilation versus synchronized intermittent mandatory ventilation plus pressure support in preterm infants with severe respiratory distress syndrome lung recruitment using oxygenation during open lung high-frequency ventilation in preterm infants aeration strategy at birth influences the physiological response to surfactant in preterm lambs early nasal intermittent positive pressure ventilation (nippv) versus early nasal continuous positive airway pressure (ncpap) for preterm infants nasal intermittent positive pressure ventilation (nippv) versus nasal continuous positive airway pressure (ncpap) for preterm neonates after extubation nasal intermittent positive pressure ventilation for preterm neonates: synchronized or not? avoiding endotracheal ventilation to prevent bronchopulmonary dysplasia: a meta-analysis the potentials and caveats of mesenchymal stromal cell-based therapies in the preterm infant publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we gratefully thank the else-kroener-fresenius-foundation (bad homburg, germany) for funding this clinical trial. authors' contributions {31b} mw and he conceived and planned the study, wrote the first draft of the study protocol, and were in charge of the overall direction and planning. arf and ce provided critical feedback on study design, were involved in the preparation of the study protocol, performed the sample size calculation, defined the statistical analysis strategy, and created the web-based study database. kpz, rs, ur, sm, mz, bb, cp, mh, and tp critically reviewed and made substantial contributions to the study design and the final study protocol. all authors read and approved the final version of the manuscript. the authors declare that they have no competing interests. the study funder is not involved nor has any responsibility in the collection, management, analysis, and interpretation of data; writing of the report; and decision to submit the report for publication. they will not have ultimate authority over any of these activities. the type of funding includes the payment of the study monitor (cpcs), staff funding, patient insurance, and patient management fees. open access funding provided by projekt deal. data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. ethics approval and consent to participate {24} ethical approval was given by the local ethics committee of the coordinating center (justus-liebig university of giessen, giessen, germany, reference number az 18/19) . the approval of ethical bodies of all participating centers is applied and pending. all pregnant women who are admitted to the local prenatal wards with threatening preterm delivery before 29 + 6/7 weeks should be approached as well as the father of the coming child and both will be asked for consent for their baby to participate in the study should it be delivered between 26 + 0 and 29 + 6 weeks of gestation. informed consent will be taken by good clinical practice (gcp) qualified staff members. written and oral information regarding study participation will be offered to both parents or legal guardian prior to birth. if the parents are not fluent in german language, consent will only be obtained if a certified and independent translator is available.author details 1 key: cord-004515-x22q1f21 authors: pottecher, julien; noll, eric; borel, marie; audibert, gérard; gette, sébastien; meyer, christian; gaertner, elisabeth; legros, vincent; carapito, raphaël; uring-lambert, béatrice; sauleau, erik; land, walter g.; bahram, seiamak; meyer, alain; geny, bernard; diemunsch, pierre title: protocol for traumadornase: a prospective, randomized, multicentre, double-blinded, placebo-controlled clinical trial of aerosolized dornase alfa to reduce the incidence of moderate-to-severe hypoxaemia in ventilated trauma patients date: 2020-03-18 journal: trials doi: 10.1186/s13063-020-4141-6 sha: doc_id: 4515 cord_uid: x22q1f21 background: acute respiratory distress syndrome continues to drive significant morbidity and mortality after severe trauma. the incidence of trauma-induced, moderate-to-severe hypoxaemia, according to the berlin definition, could be as high as 45%. its pathophysiology includes the release of damage-associated molecular patterns (damps), which propagate tissue injuries by triggering neutrophil extracellular traps (nets). nets include a dna backbone coated with cytoplasmic proteins, which drive pulmonary cytotoxic effects. the structure of nets and many damps includes double-stranded dna, which prevents their neutralization by plasma. dornase alfa is a us food and drug administration-approved recombinant dnase, which cleaves extracellular dna and may therefore break up the backbone of nets and damps. aerosolized dornase alfa was shown to reduce trauma-induced lung injury in experimental models and to improve arterial oxygenation in ventilated patients. methods: traumadornase will be an institution-led, multicentre, double-blinded, placebo-controlled randomized trial in ventilated trauma patients. the primary trial objective is to demonstrate a reduction in the incidence of moderate-to-severe hypoxaemia in severe trauma patients during the first 7 days from 45% to 30% by providing aerosolized dornase alfa as compared to placebo. the secondary objectives are to demonstrate an improvement in lung function and a reduction in morbidity and mortality. randomization of 250 patients per treatment arm will be carried out through a secure, web-based system. statistical analyses will include a descriptive step and an inferential step using fully bayesian techniques. the study was approved by both the agence nationale de la sécurité du médicament et des produits de santé (ansm, on 5 october 2018) and a national institutional review board (cpp, on 6 november 2018). participant recruitment began in march 2019. results will be published in international peer-reviewed medical journals. discussion: if early administration of inhaled dornase alfa actually reduces the incidence of moderate-to-severe hypoxaemia in patients with severe trauma, this new therapeutic strategy may be easily implemented in many clinical trauma care settings. this treatment may facilitate ventilator weaning, reduce the burden of trauma-induced lung inflammation and facilitate recovery and rehabilitation in severe trauma patients. trial registration: clinicaltrials.gov, nct03368092. registered on 11 december 2017. aerogen (ireland) will provide nebulizers to study centres at an estimated value of 28k€. after validation from its scientific committee, the traumadornase study is supported by a 300k€ grant from the french ministry of health (phrci-2017-s09). severe trauma remains a major socio-economic burden worldwide [1, 2] . indeed, it is the third cause of fatality overall, the first cause of fatality and invalidity in the 16-45 age group and the first cause of disabilityadjusted life years (dalys). aside from civilian and military trauma cases, terrorist attacks have added new threats [3] . while the first peak of trauma-associated mortality happens within the very first hours from exsanguination and severe central nervous system injuries, secondary deaths are triggered by multi-organ failure (mof) and acute respiratory distress syndrome (ards) in the intensive care unit (icu) [4] . the taxonomy of ards was recently refined by the last berlin definition [5] , which also distinguished three levels of increasing hypoxaemia severity (mild/moderate/ severe) based on the ratio of partial arterial oxygen tension (pao 2 ) over inspired oxygen fraction (fio 2 ). patients who develop moderate-to-severe ards in the icu have a worse prognosis compared to mild ards patients, including increased mortality rates (48% vs. 29%), impaired functional recovery, compromised quality of life and cognitive dysfunction [6] . severe trauma definitely remains a significant risk factor for hypoxaemia, implicating both direct and indirect lung injuries [7] . notwithstanding improvements in prehospital care, resuscitation and mechanical ventilation, the incidence of hypoxaemia in trauma patients has remained consistently high during the last 30 years [8] [9] [10] [11] . in the most severely injured trauma patients (injury severity score (iss) [12] above 15) requiring blood transfusion, the incidence of hypoxaemia may exceed 40%. indeed, a recent analysis of the prommtt registry underlines that the incidence of moderate-to-severe hypoxaemia could be as high as 45% [13] . in trauma patients, ards increases the duration of mechanical ventilation, icu and hospital lengths of stay, incidence of ventilation-acquired pneumonias, healthcare-associated costs and mortality [14] . pathophysiology of trauma-associated hypoxaemia and acute respiratory distress syndrome as previously stated [7] , severe trauma may contribute to hypoxaemia by both direct injuries (lung contusion, aspiration) and indirect injuries (non-thoracic trauma, musculoskeletal injuries, haemorrhagic shock, transfusionassociated acute lung injury [15, 16] ). whatever the mechanism implicated, inflammation is a key player [17] [18] [19] . indeed, tissue injury triggers a massive and short-lived release of damage-associated molecular patterns (damps) [20] , which bind both toll-like receptors (tlrs) [21] and receptors for advanced glycation end products (rage) [22, 23] , which recruit and activate neutrophils, resulting in a widespread systemic inflammatory response [24] . the molecular structure of damps is diverse but the most potent are made of double-stranded dna [25] , either fully (e.g. mitochondrial dna [26] [27] [28] ) or partly (e.g. nucleosomes [29] , high mobility group box-1 (hmgb1), heat shock proteins (hsp)). once bound to neutrophils, damps induce profound conformational changes in these cells (netosis), which trigger both non-self pathogen killing [30] and self tissue injury [22, 31] . indeed, netosis refers to the release of neutrophil extracellular traps (nets), composed of a backbone (decondensed chromatin fibres) coated with antimicrobial granular and cytoplasmic proteins, such as myeloperoxidase, neutrophil elastase (ne) and αdefensins [32, 33] . the detrimental effects of excessive net release are particularly important to ards, because nets can expand more easily in the pulmonary alveoli, causing extensive lung injury [33] and hypoxaemia. moreover, while unbound ne is usually rapidly inactivated when released into plasma, dna-bound ne is protected from neutralization by plasma [34] . double-stranded dna thus constitutes the backbone of both damps and nets, and prevents nets from plasma neutralization. extracellular dna is physiologically broken up by endogenous deoxyribonucleases (dnases [33, 35] ), which may become overwhelmed by a massive influx of both damps and nets. this is exacerbated as the activity of endogenous dnases is reduced in severe trauma patients (0.059 ± 0.0033 u/ml) compared to healthy controls (0.174 ± 0.031 u/ml; p < 0.0001 [36] ). however, an fda-approved recombinant dnase has been commercially available since 1994 (dornase alfa, pulmozyme; roche, basel, switzerland and genentech, san francisco, ca, usa) and prescribed for the treatment of pulmonary exacerbations in cystic fibrosis patients. as dornase alfa is usually administered via the intratracheal route (aerosols), its biological actions and pharmacokinetic properties could be an excellent prerequisite for a clinical breakthrough in trauma-induced hypoxaemia. indeed, dornase alfa was shown to reduce trauma-induced lung injury in mice [37] , to fight against sepsis-induced ards [38, 39] and to reduce mechanical ventilation-induced lung injury [40] , which are traditional "second hits" for lung damage in ventilated trauma patients. in a small, randomized clinical trial, aerosolized dornase alfa was also shown to improve oxygenation in mechanically ventilated icu patients with lobar atelectasis [41] . the primary objective of the traumadornase study is to demonstrate a reduction in the incidence of moderateto-severe hypoxaemia from 45% to 30% in severe trauma patients during the first 7 icu days by providing aerosolized dornase alfa once during the first 2 icu days as compared to equivalent provision of placebo (nacl 0.9%). the secondary objectives are to demonstrate, using aerosolized dornase alfa as compared to placebo, an improvement in static lung compliance, a reduction in mechanical ventilation duration or an increase in ventilation-free icu days, a reduction in the length of icu stay, a reduction in the hospital length of stay, a reduction in the incidence of multi-organ failure, a reduction in the incidence of ventilator-associated pneumonia (vap) and a reduction in mortality at day 30. this will be an investigator-initiated, institution-led, multicentre, double-blinded, placebo-controlled, parallel-group, superiority, randomized trial in ventilated, trauma icu patients. randomization will be carried out through a secure web-based randomization system, stratified by the centre and the presence of severe traumatic brain injury (glasgow coma score < 9 on scene). the study will be conducted in seven french participating hospitals, both university-affiliated and non-universityaffiliated. inclusion criteria will be checked before inclusion in the study. the inclusion criteria are as follows: the exclusion criteria are as follows: pregnancy or breast-feeding opposition from the patient or his/her relatives protected major (guardianship) contraindication to the use of dornase alfa known intolerance to dornase alfa patient whose life expectancy is less than 24 h, according to the treating physician "do not resuscitate" order who will take informed consent? {26a} inclusion will be feasible after patient approval, relative approval or emergency consent procedure (according to french law [42] ). subsequent confirmation of consent will be obtained from the relatives and from the patient as soon as possible. the consent forms are available from the corresponding author on request. after primary haemostasis and emergent surgical interventions, patients will be randomized in the icu within 6 h. in the case of emergent surgical intervention before icu admission, a maximum delay of 18 h will be tolerated from hospital admission (trauma bay) to study drug administration. day 0 will be considered the day of icu admission. additional consent will be required for the collection of biological specimens in ancillary studies, which will be stored for a maximum duration of 15 years. the comparator will be normal saline (nacl 0.9%, 2.5 ml, administered through the aerogen solo device). nacl is neutral regarding damps, nets and occurrence of either hypoxaemia or ards, and therefore is considered a placebo. treatment with either dornase alfa or placebo will be administered using aerosol (aerogen solo) in the ventilation circuit once per day (average treatment length: 7 min) for the first 2 days. the aerogen device was shown to optimize dornase alfa deposition in the distal lung airways [43, 44] . dornase alfa has an excellent safety profile and aerosolized nacl 0.9% has a neutral effect on lung physiology. the variables under study will be gathered every day and recorded on the electronic clinical research form (cleanweb; telemedicine technologies s.a.s., boulogne billancourt, france). for safety purposes, patient variables will be closely monitored before, during and within the first postadministration hour: lowest spo 2 , maximal value and maximal increase in peak inspiratory airway pressure, maximal value and maximal increase in plateau airway pressure, extreme values of heart rate and mean arterial pressure, skin erythema, urticaria and variations in central temperature exceeding 1°c. during the first 7 days, at least one blood gas analysis and chest x-ray will be performed every day at 8:00 a.m. to compute the primary endpoint: presence or absence of ards and severity of hypoxaemia according to the berlin definition. additional blood gas analysis will be allowed and the worst daily pao 2 /fio 2 ratio will be considered. on days 0, 3 and 5, additional blood samples (6 ml on each day) will be drawn into edta tubes, centrifuged and stored (− 80°c) for subsequent analysis of damps (mitochondrial dna by qpcr; hmgb1, hsp70 and srage by elisa) at the end of enrolment. whole blood samples will be drawn (days 0, 3 and 5) for extemporaneous quantification of nets on fresh blood using a flow cytometric assay [45] in patients at the strasbourg centre. in the case of an adverse event following treatment administration (desaturation, bronchospasm, anaphylactic reaction), treatment will be immediately discontinued and the second treatment dose will not be given on day 1. in each centre, boxes containing both full and empty treatment vials will be returned to the pharmacy responsible for clinical studies. for every included patient, a sheet will be completed (date, hour, nurse in charge) and signed for every study treatment preparation, administration and clinical surveillance. for safety purposes, patient variables will be closely monitored before, during and within the first postadministration hour: lowest spo 2 , maximal value and maximal increase in peak inspiratory airway pressure, maximal value and maximal increase in plateau airway pressure, extreme values of heart rate and mean arterial pressure, skin erythema, urticaria and variations in central temperature exceeding 1°c. at least one blood gas analysis and chest x-ray will be performed every day at 8:00 a.m. to compute the primary endpoint: presence or absence of ards and severity of hypoxaemia according to the berlin definition. additional blood gas analysis will be allowed and the worst daily pao 2 /fio 2 ratio will be taken into account. daily care for the included patients will be protocolized according to good clinical practices, especially concerning respiratory care (semi-recumbent position, protective mechanical ventilation (6-8 ml/kg predicted body weight), peep > 5 cmh 2 o, plateau pressure < 30 cmh 2 o, close tracheal cuff pressure monitoring, early enteral feeding (500 ml on day 1), glucose control and protocolized sedation based on both cpot and rass scores [46] ). adherence to guidelines will be checked in every centre for every patient. patients will be followed until day 30 for the record of study outcomes. every concomitant care will be allowed except aerosols during study drug administration. post-trial care is not planned. patients who suffer harm from trial participation will be cared for in the intensive care unit. should prejudice linked to study participation occur, financial compensation will be provided by the insurance (société hospitalière d'assurances mutuelles-sham, 18 rue edouard rochet, 69,372 lyon cedex 08, france; contract number: 143.380) contracted by the promotor (hôpitaux universitaires de strasbourg). at 6 months, the respiratory status will be assessed using the modified mrc dyspnoea questionnaire [47, 48] and a chest x-ray. the primary endpoint will be the incidence of moderate-to-severe hypoxaemia (pao 2 /fio 2 < 200, according to the berlin definition [5] ) in severe trauma patients (iss > 15) during the first 7 icu days. the pao 2 /fio 2 ratio will be computed at least once daily (8: 00 a.m.) together with the supine chest x-ray and the worst daily pao 2 /fio 2 value will be taken into account to define hypoxaemia severity. in ards patients, the severity of hypoxaemia allows for its classification according to the berlin definition and is strongly associated with mortality, length of recovery and quality of life [6, 7] . the following secondary endpoints will be recorded: static lung compliance (ml/cmh 2 o) (measured at least once daily at 8:00 a.m. during the first 7 days) duration of mechanical ventilation (h) from icu admission to first extubation success (> 48 h without reintubation) length of icu stay (h) length of stay in the hospital (days) incidence of multi-organ failure (a sofa score of 3 or more in at least two organ systems [49] ), assessed daily during the first 7 days incidence of vap according to both the american thoracic society (ats) [50] and the center for disease control and prevention (cdc) [51] definitions, assessed daily during the first 7 days the effects of dornase alfa and normal saline will be assessed according to the plasma concentrations of damps (mitochondrial dna, hmgb-1, hsp70, srage) and nets (strasbourg centre only) divided into quartiles at day 0, day 3 and day 5. it is anticipated that trauma patients with the highest blood concentrations of either damps or nets will develop the most severe complications (including hypoxaemia and ards). the time course of damp and net blood concentrations will also be analysed according to treatment group to unveil a potential quicker decrease in patients randomized in the dornase alfa group. the total duration of participation in the study will be 30 days. the forecast study duration is 36 months from first to last patient recruitment (table 1) . the sample size was determined to be 250 subjects per arm (i.e. 500 subjects in total). dornase alfa is expected to reduce the incidence of moderate-to-severe hypoxaemia from 0.45 to 0.30. considering a reasonable standard deviation of 0.03, and using bayesian techniques [52] , 200 subjects per arm were estimated to show a difference of more than 0.12 (instead of the expected 0.15). clinical examination includes physical examination (auscultation of the chest, central body temperature, positive end-expiratory pressure and inspired oxygen fraction levels) and recording of utstein criteria [49] b diagnostic tests include arterial blood gases, chest x-ray, leukocyte and platelet counts, creatinine, blood urea nitrogen, bilirubin and quantitative lung bacteriologic samplings (bronchoalveolar lavage fluid or protected specimen brush) in the case of suspected lung infection c blood withdrawal: 6 ml of blood on day 0, day 3 and day 5 d study treatment will be given on day 0 and day 1 assuming 25% loss to follow-up, this number was increased to 250 subjects per arm, although these subjects will not be replaced. patients will be recruited in seven french participating hospitals, both university-affiliated and non-universityaffiliated and admitting severe trauma patients: taken as a whole, more than 3500 patients per year fulfil the inclusion criteria, allowing for an inclusion ratio of one patient included out of seven patients admitted to one of the participating centres. randomization will be conducted over a dedicated, password-protected, ssl-encrypted website (cleanweb; telemedicine technologies s.a.s.) to allow immediate and concealed allocation. allocation will also be stratified by centre and the presence of severe traumatic brain injury (glasgow coma score < 9 on scene). the experimental study drug and placebo will be provided in identical boxes, allowing double-blind administration. the logistics of the trial fluid distribution to each of the seven participating centres that are anticipated to be recruiting will be coordinated by the pharmacy of the coordinating centre (hôpitaux universitaires de strasbourg). the allocation sequence will be computer-generated (cleanweb; telemedicine technologies s.a.s.). patients will be enrolled by registered investigators, who will also assign patients to a treatment consisting of either dornase alfa or placebo. trial participants, care providers, outcome assessors and data analysts will remain blinded after assignment to interventions, until the final analysis. unblinding is permissible whenever an adverse event occurs, via immediate request to the poison centre of the study coordinator hospital (hôpitaux universitaires de strasbourg) 24 h per day and 365 days per year. the procedure for revealing a participant's allocated intervention during the trial includes an explicit mention in the patient record. clinical research associates will ensure that patient inclusion, data collection, registry and rapport are in line with the protocol, and that the study is conducted in accordance with the good clinical practice guidelines. furthermore, clinical research associates will check the following variables: patient initials, date of birth, sex, signed consent form, eligibility criteria, date of randomization, treatment assignment, adverse events and study endpoints. the data monitoring committee is institution-based and independent from potential industrial sponsors. a dedicated card will be given to any included patient and participation in the traumadornase trial will be explicitly mentioned during transfer to another ward or hospital during handovers. data will be collected in each centre by clinical data technicians on an electronic case report form (cleanweb; telemedicine technologies s.a.s.) using double password-protected computers. pre-specified lists, range of values and drop-down menus in the electronic case report form will facilitate data entry and prevent writing errors. study documents will be deidentified, stored in each recruitment centre and kept for at least 15 years in a locked, secure office, according to french law. all personnel involved in data analysis will be masked. only the principal investigators and the statisticians will have access to the final data set. people with direct access to the data will take all necessary precautions to maintain confidentiality. all data collected during the study will be rendered anonymous. only initials and inclusion number will be registered. plans for collection, laboratory evaluation and storage of biological specimens for genetic or molecular analysis in this trial/future use {33} on days 0, 3 and 5, additional blood samples (6 ml on each day) will be drawn into edta tubes, centrifuged and stored (− 80°c) for subsequent analysis of damps (mitochondrial dna by qpcr; hmgb1, hsp70 and srage by elisa) at the end of enrolment. in patients included in the strasbourg centre, whole blood samples will be drawn (days 0, 3 and 5) for extemporaneous quantification of nets on fresh blood using a flow cytometric assay [45] . the remaining biological specimens will be stored in 0.5-ml aliquots at "biomax" biobank, statistical analyses will include a descriptive step and an inferential step using fully bayesian techniques. the estimates will use markov chains to monte carlo integrations (mcmc), choosing prior distributions to be nearly conjugated situations. unless the diagnoses for convergence give clues to the contrary, we will use three markov chains with separated starting points, a burn-in of 100,000 for each chain and 100,000 more iterations with a thinning of 25 for building a total sample of 12, 000 iterations on which the monte carlo integrations are used to retrieve characteristics of posterior distributions. the analyses will be carried out using r software (with ad hoc packages) and openbugs. sensitivity analyses will be systematically conducted, considering three scenarios with different priors: a default non-informative prior (e.g. jeffreys prior), then an optimist prior and, finally, a pessimist prior. in the descriptive step, all of the variables collected will be summarized: number and frequency for qualitative variables (ordinal and categorical) and minimum, quantiles (2.5, 25, 50, 75 and 97.5), maximum, mean and standard deviation for quantitative variables (discrete and continuous). for variables gathered over time, these descriptions will be provided globally and at each time. this description will be enriched by inference to extrapolate the observed quantities on the sample. for quantitative variables, we will assume a normal likelihood combined with a normal prior on the mean (mean 0 and variance 100) and γ on the precision (inverse of variance) with parameters 0.0005 and 0.005, and therefore mean 0.1 and variance 20. for binary variables (for which one proportion needs to be estimated), we will assume a binomial likelihood and a β prior on the proportion (jeffreys prior with parameters 0.5 and 0.5, and thus mean 0.5 and variance 0.125). for categorical variables with more than two categories, we will assume a categorical likelihood together with a dirichlet prior (jeffreys prior with all parameters at 0.5). the aim of this study is to show that the frequency of moderate-to-severe hypoxaemia is lower in the dornase alpha group than in the placebo group. the main variable is then dichotomous "moderate-to-severe hypoxaemia yes/no", modelled in a logistic mixed regression. we will assume that this variable is bernoulli distributed with parameter π. the logit of this parameter (linear predictor) is additively written as: where: α 0 is a grand mean, with mean 0 normal prior (the variance in this normal is 6, corresponding to a low informative prior) i(g i = 1) is a dummy covariate coded for the group of subject i (1 for the dornase alpha group and 0 for the placebo group)the prior on the parameter of this covariate is the same normal as that for the grand mean β i is a (random) subject effect, on which is assumed a normal prior with mean 0 and low variance (e.g. 10) because the linear predictor is on the logit scale, the probability for moderate-to-severe hypoxaemia will be obtained by monitoring the back-transformation of the logit. this regression model without covariates except group will be completed for taking into account potential confounding variables. in the model, the entire set of these variables will be added and, secondly, selected using stochastic search variable selection (ssvs) [53] . in such a model, the prior distribution on each parameter is a mixture of two mean 0 normal distributions, one with low variance and the other with high variance: if the posterior weight on this second normal is strongly around 0, then the prior on the parameter is essentially driven by a normal distribution whose mean is centred on 0; this is the clue for a "non-significant" parameter. the secondary analyses will be conducted as the main analysis with a regressive model, testing the difference of a parameter between the two groups. only the likelihood model will be changed to take into account the type of variable studied: γ distribution for continuous variables such as length of stay and duration of ventilation. dichotomous variables such as 30-day mortality will be studied with logistic regression. no statistical procedure for replacing missing values will be used. all variables and subjects will be considered in the descriptive analyses, but, for inference, 20% missing data or more will result in rejection of the variable or individual. an interim analysis will be performed after inclusion of the first 250 patients. these preliminary data will be available to the data safety and monitoring board (see later for details), which will have the ability to stop the trial for either futility or harm. analyses will be performed in intention to treat. to verify the impact of possible deviations from the protocol, these analyses will be supplemented by an analysis per protocol. subgroup analyses will be conducted according to the glasgow coma scale on site (score either ≤ 8 or > 9). methods in analysis to handle protocol non-adherence and any statistical methods to handle missing data {20c} no statistical procedure for replacing missing values will be used. all variables and subjects will be considered in the descriptive analyses, but, for inference, 20% missing data or more will result in rejection of the variable or individual. plans to give access to the full protocol, participant-level data and statistical code {31c} the protocol is available on the clinicaltrials.gov website (https://clinicaltrials.gov/ct2/show/nct03368092?term= traumadornase&draw=2&rank=1). study documents will be de-identified, stored in each recruitment centre and kept for at least 15 years in a locked, secure office, according to french law. all personnel involved in data analysis will be masked. only the principal investigators and the statisticians will have access to the final data set. composition of the data monitoring committee, its role and reporting structure {21a} the data safety and monitoring board (dsmb) will include dr laure peyro-saint paul (drug monitoring specialist), prof. bernard asselain (methodologist and biostatistician), prof. catherine paugam-burtz (anaesthesiologist and intensive care physician), prof. samir jaber (anaesthesiologist and intensive care physician) and prof. boris jung (intensive care physician). the dsmb, independent from the study sponsor and principal investigator, including three intensive care physicians, one methodologist and one drug safety specialist, will meet after inclusion of the first 20 patients to assess the safety of dornase alfa administration in ventilated trauma patients. the safety variables under study are detailed in the "interventions" section. the dsmb will meet subsequently after further incremental inclusions of 100 patients. the dsmb charter was signed by all of its members. adverse events and unintended effects of the trial intervention or trial conduct will be declared to the promotor within 24 h of occurrence. moreover, the dsmb will meet after inclusion of the first 20 patients to assess the safety of dornase alfa administration in ventilated trauma patients. the safety variables under study are detailed in the following. for safety purposes, patient variables will be closely monitored before, during and within the first post-administration hour: lowest spo 2 , maximal value and maximal increase in peak inspiratory airway pressure, maximal value and maximal increase in plateau airway pressure, extreme values of heart rate and mean arterial pressure, skin erythema, urticaria and variations in central temperature exceeding 1°c. the dsmb will meet subsequently after further incremental inclusions of 100 patients. in every centre, an audit will be performed by the direction de la recherche clinique des hôpitaux universitaires de strasbourg after inclusion of the first patient, then yearly and after enrolment of the last patient. plans for communicating important protocol amendments to relevant parties (e.g. trial participants, ethical committees) {25} important protocol modifications will be communicated to investigators, irb and trial registries via e-mail. every protocol amendment will be first submitted to the irb and, after validation, transmitted to investigating centres, which will acknowledge receipt. the results of the study will be released to the participating physicians, referring physicians and medical community no later than 1 year after the completion of the trial, through presentation at scientific conferences and publication in peer-reviewed journals. eligible authors will meet all four requirements of the icmje guidelines: substantial contributions to the conception or design of the work; or the acquisition, analysis or interpretation of data for the work drafting the work or revising it critically for important intellectual content final approval of the version to be published agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved to the best of our knowledge, traumadornase is the first large-scale study to evaluate the usefulness of inhaled dornase alfa to reduce the incidence of moderate-to-severe hypoxaemia in a population of severe trauma patients, who will also benefit from other lung-protective measures. the benefits are expected to include a reduction in both duration of mechanical ventilation and stay in the icu, lower costs of hospital stay, fewer days on mechanical ventilation and a reduction in the selective pressure on multidrug-resistant bacteria. in order to keep management practices as standardized as possible, we decided to limit the number of investigating centres to seven university-affiliated and non university-affiliated hospitals, all of which are recognized in the field of trauma care and treat more than 50 severe trauma patients per year. these centres belong to the traumabase network (www.traumabase.eu), which promotes multicentre clinical research on trauma and ensures consistent recording of clinical data according to the traumabase registry guidelines. these seven centres also share the same standards of care and, except for pitié-salpêtrière centre, belong to the same region of france (grand est). from a translational point of view, the study will challenge the hypothesis that breaking up the doublestranded dna backbone of both damps and nets with dornase alfa may reduce inflammation and netinduced epithelial and endothelial cell injuries in the lungs of trauma patients. dornase alfa is a long-standingfda-approved mucolytic agent used in cystic fibrosis patients. its safety profile and limited side effects make it an appropriate candidate to curb damp-induced, net-mediated inflammation. as we will use high-end vibrating mesh nebulizers, which provide excellent lung deposition and drug bioavailability, we expect that dornase alfa will be deposited within the depth of the lung parenchyma, where it may be the most useful. the incidence of moderate-to-severe hypoxaemia is the primary study endpoint. a 45% basal incidence of moderate-to-severe hypoxaemia may appear overstated to some experts, but it must be underlined that only severe trauma patients will be included and that a 45% incidence was reported in the last randomized promtt trial [13] , in the era of damage-control resuscitation [54] . a 15% absolute reduction seems ambitious for a single intervention. however, previous studies using dornase alfa in animal lung injury models and in ventilated patients suffering atelectasis demonstrated striking results [35, [38] [39] [40] [41] 55] . because fluid loading regimens and transfusion strategies are based on local written protocols, they may act as potential confounding variables. however, this will be controlled by the stratification of the randomization at the centre level and adjustment of statistical analyses in cases of differences between groups. in conclusion, this trial is the first multicentre, randomized controlled, double-blinded study adequately powered to test the hypothesis that aerosolized dornase alfa reduces the incidence of moderate-to-severe hypoxaemia in mechanically ventilated severe trauma patients. protocol version 8.0 was approved by the national institutional review board on 6 november 2018. the study started on 10 march 2019 and is expected to last until september 2022 (36-month inclusion period plus 6month participation period). after validation from its scientific committee, the traumadornase study was funded by the french ministry of health. fédération hospitalo-universitaire omicare, centre de recherche d inserm umr_s 1158 neurophysiologie respiratoire expérimentale et clinique, ap-hp, groupe hospitalier pitié-salpêtrière charles foix, département d'anesthésie réanimation réanimation chirurgicale et traumatologique, samu 51, 45 rue cognacq-jay, 51092 reims, france. 10 hôpitaux universitaires de strasbourg, nouvel hôpital civil, laboratoire central d'immunologie, 1 place de l'hôpital, 67091 strasbourg cedex service de physiologie et d'explorations fonctionnelles disability-adjusted life years (dalys) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the global burden of disease study the toll of death and disability from traumatic injury in the united states-the "neglected disease" of modern society, still neglected after 50 years icu specialists facing terrorist attack: the nice experience distribution of the probability of survival is a strategic issue for randomized trials in critically ill patients acute respiratory distress syndrome: the berlin definition functional disability 5 years after acute respiratory distress syndrome acute respiratory distress syndrome incidence of adult respiratory distress syndrome in trauma patients: a systematic review and meta-analysis over a period of three decades clinical predictors of early acute respiratory distress syndrome in trauma patients the acute respiratory distress syndrome following isolated severe traumatic brain injury heterogeneous phenotypes of acute respiratory distress syndrome after major trauma the injury severity score revisited application of the berlin definition in prommtt patients: the impact of resuscitation on the incidence of hypoxemia acute lung injury and the acute respiratory distress syndrome in the injured patient potential contribution of mitochondrial (mt) dna damage associated molecular patterns (damps) in transfusion products to the development of acute respiratory distress syndrome (ards) after multiple transfusions transfusion-related acute lung injury: the work of damps a genomic storm in critically injured humans sterile inflammation: sensing and reacting to damage microbial recognition and danger signals in sepsis and trauma plasma levels of danger-associated molecular patterns are associated with immune suppression in trauma patients toll-like receptors in the vascular system: sensing the dangers within the hmgb1/rage axis triggers neutrophil-mediated injury amplification following necrosis the hmgb1-rage inflammatory pathway: implications for brain injury-induced pulmonary dysfunction trauma surgery 3. advances and future directions for management of trauma patients with musculoskeletal injuries circulating mitochondrial damps cause inflammatory responses to injury clinical immunology: culprits with evolutionary ties elevated levels of plasma mitochondrial dna damps are linked to clinical outcome in severely injured human subjects plasma mitochondrial dna levels in patients with trauma and severe sepsis: time course and the association with clinical status circulating histones are mediators of trauma-associated lung injury neutrophil recruitment and function in health and inflammation neutrophil extracellular traps directly induce epithelial and endothelial cell death: a predominant role of histones role of neutrophil extracellular traps following injury neutrophil extracellular traps in pulmonary diseases: too much of a good thing molecular mechanisms of net formation and degradation revealed by intravital imaging in the liver vasculature dnasei protects against paraquat-induced acute lung injury and pulmonary fibrosis mediated by mitochondrial dna reduced deoxyribonuclease enzyme activity in response to high postinjury mitochondrial dna concentration provides a therapeutic target for systemic inflammatory response syndrome targeting neutrophils to prevent malaria-associated acute lung injury/acute respiratory distress syndrome in mice mitochondrial dna damage associated molecular patterns in ventilatorassociated pneumonia: prevention and reversal by intratracheal dnase i mitochondrial dna damage-associated molecular patterns mediate a feedforward cycle of bacteria-induced vascular injury in perfused rat lungs mechanical ventilation induces neutrophil extracellular trap formation inhaled dornase alfa (pulmozyme) as a noninvasive treatment of atelectasis in mechanically ventilated patients french legal approach to clinical research aerosol delivery of recombinant human dnase i: in vitro comparison of a vibrating-mesh nebulizer with a jet nebulizer a technical feasibility study of dornase alfa delivery with eflow flow cytometric assay for direct quantification of neutrophil extracellular traps in blood samples hospital-acquired pneumonia in icu evaluation of clinical methods for rating dyspnea the body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease reversal of trauma-induced coagulopathy using first-line coagulation factor concentrates or fresh frozen plasma (retic): a single-centre, parallelgroup, open-label, randomised trial infectious diseases society of america. guidelines for the management of adults with hospital-acquired, ventilatorassociated, and healthcare-associated pneumonia complications of mechanical ventilation-the cdc's new surveillance paradigm bayesian and mixed bayesian/likelihood criteria for sample size determination variable selection via gibbs sampling the prospective, observational, multicenter, major trauma transfusion (prommtt) study: comparative effectiveness of a time-varying treatment with competing risks local dornase alfa treatment reduces nets-induced airway obstruction during severe rsv infection publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors are greatly indebted to barbara jung and mathias candusso, clinical research associates, for writing the study draft. the authors thank jo-ann elicia west, msc, an independent consultant in cartigny l'epinay, france, for providing editorial support, which was funded by hôpitaux universitaires strasbourg, direction de la recherche clinique et des innovations, strasbourg, france in accordance with good publication practice (gpp3) guidelines (http://www.ismpp.org/gpp3). jp conceived the study, coordinated its design, drafted and wrote the manuscript. jp, en, mb, ga, sg, cm, eg, vl, rc, bu-l, es, wgl, sb, am, bg and pd read and were involved in critical appraisal and revision of the manuscript. es provided statistical expertise. all authors approved the final manuscript prior to submission. aerogen (ireland) will provide nebulizers to the study centres (estimated value: €28,000). after validation from its scientific committee, the traumadornase study is supported by a €300,000 grant from the french ministry of health (phrci-2017-s09). funders will have no role in the study's design, collection, management, analysis and interpretation of data, writing of the report and the decision to submit the report for publication conception or in the data analysis. name and contact information for the trial sponsor: ms nathalie portier, french ministry of health, girci est, chu de dijon, 14, rue paul gaffarel, bp 77908, 21079 dijon cedex, france. only the principal investigators, the dsmb and the statisticians will have access to the final data set. the data sets used and analysed during the current study will be available from the corresponding author on reasonable request, after publication of the main core article. the clinical trial will adhere to the principles of the declaration of helsinki and to the clinical trials directive 2001/20/ec of the european parliament on the approximation of the laws, regulations and administrative provisions of the member states relating to the implementation of good clinical practices in the conduct of clinical trials on medicinal products for human use. ethical aspects of this research project have been approved by the french agence nationale de la sécurité du médicament et des produits de santé (ansm, on 5 october 2018) and a national institutional review board (cpp, on 6 november 2018), which covers all participant sites. the trial will be monitored by the research monitoring officers of strasbourg university hospital. significant changes to the protocol will be submitted for approbation by the national institutional review board. prior consent of the subject will not be possible in most cases due to traumatic brain injury, haemorrhagic shock or prehospital sedation requirements. therefore, consent of the subject's legally acceptable representative will be requested. a consent form specifically designed for the subject's legally acceptable representative will be provided with documented approval or favourable opinion of the institutional review board in order to protect the rights, safety and well-being of the subject and to ensure compliance with any applicable regulatory requirements. consent to participation in the study by the patient's relatives will be solicited, according to the requirements of the ethics committee. in cases where neither patient consent nor relative's consent is available within the 6-h inclusion timeline, the subject will be included following the emergency consent procedure (according to french law [42] , code de la santé publique, article l1122-1). subsequent confirmation of consent will be obtained from the relatives and the patient as soon as possible. although it is not anticipated, owing to the trial design, publication of any personal information about a patient will require her/his consent. the authors declare that they have no competing interests. 1 key: cord-004646-zhessjqh authors: bawazeer, mohammed; amer, marwa; maghrabi, khalid; alshaikh, kamel; amin, rashid; rizwan, muhammad; shaban, mohammad; de vol, edward; hijazi, mohammed title: adjunct low-dose ketamine infusion vs standard of care in mechanically ventilated critically ill patients at a tertiary saudi hospital (attainment trial): study protocol for a randomized, prospective, pilot, feasibility trial date: 2020-03-20 journal: trials doi: 10.1186/s13063-020-4216-4 sha: doc_id: 4646 cord_uid: zhessjqh background: a noticeable interest in ketamine infusion for sedation management has developed among critical care physicians for critically ill patients. the 2018 pain, agitation/sedation, delirium, immobility, and sleep disruption guideline suggested low-dose ketamine infusion as an adjunct to opioid therapy to reduce opioid requirements in post-surgical patients in the intensive care unit (icu). this was, however, rated as conditional due to the very low quality of evidence. ketamine has favorable characteristics, making it an especially viable alternative for patients with respiratory and hemodynamic instability. the analgo-sedative adjunct ketamine infusion in mechanically ventilated icu patients (attainment) trial aims to assess the effect and safety of adjunct low-dose continuous infusion of ketamine as an analgo-sedative compared to standard of care in critically ill patients on mechanical ventilation (mv) for ≥ 24 h. methods/design: this trial is a prospective, randomized, active controlled, open-label, pilot, feasibility study of adult icu patients (> 14 years old) on mv. the study will take place in the adult icus in the king faisal specialist hospital and research center (kfsh&rc), riyadh, saudi arabia, and will enroll 80 patients. patients will be randomized post-intubation into two groups: the intervention group will receive an adjunct low-dose continuous infusion of ketamine plus standard of care. ketamine will be administered over a period of 48 h at a fixed infusion rate of 2 μg/kg/min (0.12 mg/kg/h) in the first 24 h followed by 1 μg/kg/min (0.06 mg/kg/h) in the second 24 h. the control group will receive standard of care in the icu (propofol and/or fentanyl and/or midazolam) according to the kfsh&rc sedation and analgesia protocol as clinically appropriate. the primary outcome is mv duration until icu discharge, death, extubation, or 28 days post-randomization, whichever comes first. discussion: the first patient was enrolled on 1 september 2019. as of 10 october 2019, a total of 16 patients had been enrolled. we expect to complete the recruitment by 31 december 2020. the findings of this pilot trial will likely justify further investigation for the role of adjunct low-dose ketamine infusion as an analgo-sedative agent in a larger, multicenter, randomized controlled trial. trial registration: clinicaltrials.gov: nct04075006. registered on 30 august 2019. current controlled trials: isrctn14730035. registered on 3 february 2020. sedation and analgesia management are both integral components of care in the intensive care unit (icu). although benzodiazepines have been the mainstay therapy for sedation in critically ill patients, their use has declined in recent years, with favoring of nonbenzodiazepines, such as propofol and dexmedetomidine. this change in practice is based on studies demonstrating the association between the sustained use of benzodiazepines and increased mechanical ventilation (mv) duration, icu length of stay (los), and development of delirium. a paradigm shift has therefore occurred in the management of patients' sedation in the icu. maintenance of light levels of sedation in adult patients in the icu has been recommended to improve patient clinical outcomes, such as shorter duration of mv and shorter icu los [1] . a noticeable interest in ketamine infusion for sedation management in critically ill patients has developed among critical care physicians [2] . the 2018 pain, agitation/sedation, delirium, immobility, and sleep disruption (padis) guideline suggested low-dose ketamine as an adjunct to opioid therapy for reducing opioid consumption in post-surgical adults admitted to the icu (i.e., conditional recommendation, very low quality of evidence) [1] . in a single-center, double-blind, randomized controlled trial (rct) of 93 icu post-abdominal surgery patients, adjunctive ketamine was associated with a reduced intake of morphine. however, there were no differences in patients' self-reported pain intensity [3] . ketamine was administered as 0.5 mg/kg intravenous (iv) push followed by infusion of 2 μg/kg/min (0.12 mg/kg/h) × 24 h, then 1 μg/kg/ min × 24 h (0.06 mg/kg/h). the incidence of side effects (i.e., nausea, delirium, hallucination, hypoventilation, pruritus, and sedation) did not differ between the ketamine and opioidalone groups. based on this generally positive icu rct, the 2018 padis panel made a conditional recommendation for the use of low-dose ketamine as an adjunct to opioids to optimize acute post-operative pain management in critically ill adults (refer to supplementary table 1 : previous ketamine trials in the icu setting) [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] . because of an increased focus on ensuring that pain is appropriately controlled in patients before using sedative-hypnotic medications (also known as the analgo-sedation approach), ketamine has gained attention for its unique pharmacologic properties that could address both the analgesic and sedative requirements. ketamine could result in decreased duration of mv while providing optimal levels of sedation [12] . similar to dexmedetomidine, ketamine has a non-gabaergic mechanism of action [13] . it induces rapid sedation and analgesia through dual mechanisms mediated by inhibition of the n-methyl-d-aspartate receptor and activation of the opioid μand κ-receptors [14] . ketamine is also saudi food and drug authority (fda)-approved for the induction of anesthesia and has been used for acute and chronic pain in sub-anesthetic dose, post-operative opioid sparing, rapid sequence intubation, and procedural sedation and analgesia [15] . additionally, ketamine has favorable characteristics, including bronchodilation, preservation of cardiac output, increase in blood pressure, minimal effects on bowel motility, and maintaining of respiratory drive and airway reflexes while actively weaning from mv; these features make it an especially viable alternative for patients with respiratory and hemodynamic instability [12] . although commonly used sedatives are effective, they have side effects including benzodiazepine-associated delirium, opioid-induced constipation, and the negative hemodynamic effect caused by propofol and dexmedetomidine [1, [16] [17] [18] . the most frequently observed adverse effects associated with ketamine when used to maintain sedation include tachycardia (6.7%), hypertension (6%), paradoxical agitation (up to 20%), and hypersalivation (12%) [12] . although there is limited literature on adults, as many as 57% of pediatric patients who receive ketamine for continuous sedation experience the emergence phenomenon, including vivid hallucinations and delirium during or after ketamine use [19] . when ketamine is used for procedural sedation in adults (usually administered as a relatively high dose, 1-2 mg/kg repeated q5-15 min to maximum 100 mg), up to 20% of patients may develop the emergence phenomenon [20] . risk factors for delirium with ketamine include prior history of psychiatric disorders, dementia, and the use of a high dose in procedural sedation [20] . the development of the emergence phenomenon can cause patients to transiently require higher amounts of other sedatives, usually benzodiazepines. however, ketamine-based analgo-sedation in mv patients administered as a subanesthetic/sub-dissociative/low dose results in similar numbers of delirium-and coma-free days as those in non-ketamine-based regimens, as shown in a retrospective cohort study conducted by shurtleff et al. at an academic medical center [8] . ketamine infusion in this trial was 5 μ g/ kg/min (0.3 mg/kg/h) titrated using 5 μ g/kg/min every 5 min up to a maximum of 25 μ g/kg/min (1.5 mg/kg/h). the authors found that the number of days alive without delirium or coma was 6 days (interquartile range [iqr] 2-9 days) with ketamine and 4 days (iqr 3-7 days) with a non-ketamine medication (p = 0.351). delirium occurred in 29 of the 39 patients (74%) with ketamine and in 34 of the 40 patients (85%) with the non-ketamine drug (p = 0.274). similarly, the rct cited by the 2018 padis guideline showed that the incidence of side effects (i.e., delirium and hallucinations) did not differ between the ketamine and opioid-alone groups [3] . at king faisal specialist hospital and research center (kfsh&rc), continuous infusions of sedatives and analgesics are prescribed at the physician's discretion and titrated to achieve richmond agitation-sedation scale (rass) and pain scores; the infusions are performed with a nurse-driven protocol. the protocol promotes analgesia-first sedation (with fentanyl) and recommends propofol as the first-line agent when sedation is required. patients receive a daily spontaneous awakening trial (sat) paired with a spontaneous breathing trial (sbt). the rass and the confusion assessment method for the icu (cam-icu) are routinely used to assess the level of sedation and the presence of delirium, respectively. ketamine, registered by the ministry of health of saudi arabia, is a kfsh&rc hospital formulary medication and is listed in the kfsh&rc icu pain and sedation protocol as an option for patients with severe bronchospasm. however, the order or the combination that could be most effective with ketamine is unclear (refer to supplementary figure 1 : kfsh&rc new sedation protocol for adult icus). as stated previously, the 2018 padis guideline listed ketamine as a conditional recommendation, with very low quality of evidence (limited high-level evidence). most trials listed in supplementary table 1 are in surgical icu settings, retrospective in nature, or are rcts focused on comparing ketamine to placebo or two study drugs (e.g., ketamine vs opioid). however, most patients in the icu are sedated with a combination of drugs. moreover, most trials had a limited focus on patientcentered outcomes, such as duration of mv or icu los, as the primary outcome favoring surrogate outcomes, such as sedation scores and changes in analgesics and sedatives [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] . to help further delineate ketamine's role as a maintenance analgo-sedation agent in the icu, further rcts need to be conducted to compare the effects of ketamine to those of other analgesics and sedatives on reducing the duration of mv, icu los, and delirium occurrence. recently, there was a prospective, double-blinded, multicenter rct (kemimof) in critically ill patients > 12 years old and requiring sedation for > 24 h in the icu, in uganda. patients were randomized to receive either ketamine-midazolam or morphinemidazolam given as premixed 50-ml syringes for infusion. the primary outcome measures were duration of mv, incidence of hypotension, and incidence of delirium. the trial was terminated on 28 august 2019 with pending results. limitations of this trial are the use of premixed syringes, which are not typically used in adult icu sedation practice, and the focus on comparing two study drugs (ketamine vs morphine) [21] . robust clinical outcome data and comprehensive assessments of adverse events (aes) associated with ketamine use in mechanically ventilated patients are limited, leaving a significant knowledge gap, which has been reflected in the wide variation in the use of ketamine as a sedative agent in icus. this is also highlighted in a recent systematic review and meta-analysis by manasco et al. [22] . therefore, we propose a prospective, randomized, active controlled, open-label, pilot, feasibility study to assess the effect and safety of analgo-sedative ad-junct ketamine infusion in mechanically ventilated icu patients (the attainment trial) compared to standard of care alone. we hypothesized that low-dose ketamine infusion will reduce the duration of mv with an acceptable safety profile compared to standard of care. the findings of this pilot trial will likely justify further investigations on the role of adjunct low-dose ketamine infusion as an analgo-sedative and inform the design of a large multicenter rct with sufficient power to detect differences in clinical outcomes. the primary objective the primary objective is to study the feasibility and effect of adjunct low-dose ketamine infusion on mv duration compared to the standard of care alone in critically ill patients. secondary objectives are to study the effect of adjunct low-dose ketamine infusion on the following: 1. the cumulative dose of pain and sedative medications 2. the incidence of dexmedetomidine use postrandomization 3. the number of patients within rass and pain score goals 4. the hemodynamic status in terms of vasopressor therapy requirement 5. icu and hospital los 6. tracheostomy, unplanned extubation, and reintubation rates 7. the incidence of delirium and rate of positive cam-icu assessment 8. the rate of antipsychotic use for icu-acquired delirium 9. the rate of hypersalivation and frequent suctioning 10. the rate of using physical restraint 11. mortality rate at 28 days. the attainment trial is a prospective, randomized, open-label, active controlled, parallel group, pilot, feasibility, phase 3 study of adult patients admitted to the kfsh&rc adult icus, riyadh, saudi arabia. this trial is approved by the institutional review board (irb) of the kfsh&rc. the trial is registered in clinicaltrials.gov: nct04075006, current controlled trials: isrctn14730035, and saudi food and drug authority: sctr #19063002. the protocol adheres to the standard protocol items: recommendations for interventional trials (spirit) guidelines (see supplementary file 1 and supplementary table 2 ). the inclusion criteria are as follows: adult patients (> 14 years old) on mv admitted to one of the following icus: medical, surgical, or transplant/oncology icu intubated within the previous 24 h expected to require mv for more than 24 h expected to be on the kfsh&rc icu sedation and pain protocol no objection from the icu attending physician for enrollment the exclusion criteria are: patients with a history of dementia or psychiatric disorders or those on any antipsychotic or antidepressant medications at home pregnancy age < 14 years old expected to need mv < 24 h known hypersensitivity to ketamine patients with expected targeted rass score of − 5, e.g., patients on continuous infusion neuromuscular blockade patients on dexmedetomidine as the primary sedative prior to randomization patients with cardiogenic shock, acute decompensated heart failure, or myocardial infarction history of end-stage liver failure (child-pugh score c) proven or suspected primary neurological injury (traumatic brain injury, ischemic stroke, intracranial hemorrhage, spinal cord injury, anoxic brain injury, brain edema) patients with persistent heart rate (hr) > 150 beats per minute (bpm) or systolic blood pressure (sbp) > 180 mmhg patients identified as do not resuscitate (dnr) or those expected to die within 24 h patients on extracorporeal membrane oxygenation (ecmo) patients with refractory status epilepticus who are receiving ketamine infusion proven or suspected status asthmaticus. the study is conducted according to good clinical practice guidelines. the study protocol as well as the informed consent have been approved by the research ethics committee (rec) and clinical research committee (crc) at kfsh&rc with research advisory council (rac) number 2191 187. once an eligible patient is identified, study investigators start the consenting process to explain the objectives of the trial and its potential risks and benefits to the patient's surrogate decision-maker. a verbal consent from a guardian/next of kin over the phone is considered to allow randomization and initiation of timely intervention when written authorization cannot be secured in sufficient time (within 24 h of intubation). verbal consent is documented in medical records to indicate the research subject's acceptance to participate in the study. a prospective written consent is obtained thereafter from the patient (if extubated) or the patient's guardian/next of kin once they become available. patients will be randomized into two groups: the intervention group will receive an adjunct low-dose continuous infusion of ketamine plus the standard of care in the icu. ketamine will be administered over a 48-h period at a fixed infusion rate of 2 μg/kg/min (0.12 mg/kg/h) for the first 24 h followed by 1 μg/kg/min (0.06 mg/kg/h) in the second 24 h. the control group will receive the standard of care in the icu, where propofol and/or fentanyl and/or midazolam will be given according to the kfsh&rc icu sedation and analgesia protocol as clinically appropriate. other aspects of care in both groups, including rass goal, sat, sbt, mobilization, and non-pharmacological interventions to promote comfort and facilitate sleep, will be left to the discretion of the icu attending physician. please refer to fig. 1 : study methodology. the intervention may be stopped in the following situations (see table 1 for more details): the icu team deemed that excessive sedation is persisting after holding or decreasing the other sedatives (propofol and/or fentanyl and/or midazolam) and the patient is not in target rass. adverse effects: persistent tachycardia with hr > 150 for ≥ 3 h, persistent hypertension with sbp > 180 for ≥ 3 h, uncontrolled agitation (removing tubes and lines) and combative behavior. patient died or goals of care changed to comfort care. patient is weaned off sedation and/or extubated. patients will be randomly assigned to one of two study groups in a 1:1 ratio by a computer-generated randomization list created by an independent biostatistician; no stratification will be performed. our initial screening and eligibility assessment is done by bedside icu nurses who are blinded to treatment assignment. to further ensure allocation concealment, access to the randomization will be restricted to a pharmacist (third party and not part of the study) to whom principal investigators refer at a distance (by telephone) to know the assigned treatment. the study investigators and study participants during the recruitment and consenting process will be blinded to the treatment assignment. once the consenting process is complete, the principal investigators will contact the pharmacist (third party) for patient table 1 intervention stopping rules and protocol deviation events action regarding the intervention (ketamine) action regarding the study procedure (data collection and data analysis) completed 48 h ketamine will be discontinued (intended duration for this trial is 48 h). continuation of ketamine or other analgesics and sedatives for more than 48 h will be left to the treating physicians, but will not be related to the research purpose subject will be included in the data analysis positive cam-icu score for delirium and hallucination within the first 48 h ketamine will be continued, and delirium treatment (nonpharmacological and antipsychotic use) will be left to the treating physicians. in cases of uncontrolled agitation (removal of tubes and lines and combative behavior) within the first 48 h, ketamine will be discontinued (refer to protocol deviation below) subject will be included in the data analysis (safety outcome data) use of physical restraint within the first 48 h ketamine will be continued unless uncontrolled agitation (removal of tubes and lines and combative behavior) within the first 48 h, in which case ketamine will be discontinued (refer to protocol deviation below) subject will be included in the data analysis (safety outcome data) hypersalivation and frequent suctioning within the first 48 h ketamine will be continued and management of hypersalivation will be left to the treating physicians subject will be included in the data analysis protocol deviation (patient did not complete the intended duration of the trial (i.e., 48 h) ketamine will be discontinued all information will be removed and not included in the analysis (modified intentionto-treat principle) patient extubated and sedation weaned off within the first 48 h ketamine will be discontinued subject will be included in the data analysis if the icu team believed the patient is not in target for rass within the first 48 h when the patient is deemed to be excessively sedated after receiving ketamine and other sedatives (propofol and/or fentanyl and/or midazolam), the other sedatives will be held first (or decreased) and ketamine will be continued until the subject reaches the team's desired rass goal. in situations where excessive sedation persisted and the patient is not yet in target rass, then ketamine will be discontinued when the patient is deemed to be agitated after receiving ketamine and other sedatives (propofol and/or fentanyl and/or midazolam), the other sedatives will be increased, use as needed boluses, or add dexmedetomidine. the decision to continue or discontinue ketamine infusion will be left to the discretion of the treating physicians subject will be included in the data analysis persistent tachycardia with hr > 150 for > 3 h within the first 48 h if the icu treating physicians believes that ketamine is the primary causative factor, ketamine will be discontinued and patient will be followed up for 24 h. detailed documentation will be carried out in the medical record for adverse event, severity of event, recovery from event, group allocation, and relation to study protocol subject will be included in the data analysis ketamine will be discontinued subject will be included in the data analysis (safety outcome data) physician decline after randomization ketamine will be discontinued subject will be included in the data analysis a in cases of death (either within the first 48 h, until icu or hospital discharge, or 28 days after randomization, whichever comes first), detailed documentation will be carried out in the medical record for the cause of death, group allocation, and relation to study protocol allocation and initiation of the trial intervention. group allocation will be concealed until after randomization. the study interventions will continue for 48 h from the time of randomization. patients and medical charts will be followed at baseline prior to randomization and at 24 h and 48 h post-randomization. medical charts will also be followed to document the outcomes at 28 days, or until death, whichever comes first. please refer to fig. 2 for the schedule of enrollment, interventions, and assessments. the study investigators and study participants during the recruitment and consenting process will be blinded to the treatment assignment. once the trial intervention starts, the treating team and study investigators will not be blinded to the trial intervention for practical and safety purposes (open label). the study statistician is blinded to the treatment allocation, and the study investigators will remain blinded to the results until the conclusion of the study. the principal investigators will ensure enrollment of patients as quickly as possible after 24 h post-intubation. patients intubated for more than 24 h will be excluded to eliminate early contamination or confounders. the primary outcome is median duration of mv: the number of calendar days from intubation date to extubation date, until icu discharge, death, or 28 days post-randomization, whichever comes first. this outcome was chosen as a patient-centered outcome and based on the mechanistic plausibility data that showed ketamine possibly has a bronchodilatory effect and maintains respiratory drive and airway reflexes [9, 12, 13] . because duration of mv is highly influenced by mortality, the median ventilator-free days to day 28 post-randomization will be calculated as a co-primary outcome [23] . see the statistical methods in "data analysis." secondary clinical outcomes 3. proportion of patients achieving the rass goal and pain score goal within the first 48 h after randomization 4. proportion and median vasopressor requirements in the first 48 h after randomization 5. median change in mean arterial pressure (map) and hr in the first 48 h after randomization 6. icu and hospital los: number of calendar days (median, iqr) from randomization to discharge date from the icu or hospital 7. proportion of tracheostomy, unplanned extubation (self-extubation), and re-intubation within 28 days post-randomization 8. proportion of patients starting on antipsychotics and positive cam-icu score to assess the incidence of delirium 48 h after randomization. the presence of delirium will also be confirmed through a psychiatrist consultation 9. proportion of physical restraint 48 h after randomization 10. proportion of patients with frequent suctioning in the first 48 h after randomization (defined as interval between suctioning episodes 2 h or less) 11. mortality rate at the time of hospital discharge or 28 days after randomization, whichever comes first. secondary feasibility outcomes: 1. proportion of screened patients 2. proportion of eligible patients enrolled 3. enrollment rate (i.e., number of enrollments per month) 4. protocol compliance. data will be collected in the kfsh&rc research electronic data capture (redcap) platform. each subject will be given a unique subject id number (database numbers and all identifiers will be removed). a subject id key will be used to match the subjects' medical record numbers and will be kept in a password-protected file that is accessible to the principal investigators. access to the redcap data will be limited to the principal investigators and co-investigators involved in data collection only. access to redcap requires authentication (username and password) for secure maintenance of the data. all investigators are kfsh&rc employees and have access to the electronic medical record (power chart). all collected information will be stored in a secure manner, and all patient data will be kept confidential. to ensure consistency in data collection, training sessions will be held by the principal investigators for all research co-investigators involved in data collection prior to study commencement. additionally, the principal investigators will conduct educational sessions for icu physicians and icu nurses, which will include the study protocol, and periodic follow-up educational sessions to provide feedback and ensure optimal compliance with the study protocol. there will be periodic internal audits of data entry accuracy and compliance by the principal investigators. this will allow us to identify any protocol deviations and provide an opportunity for feedback to the co-investigators involved in data entry. range edits and value checks will be incorporated into the redcap software to minimize the potential for data entry errors. moreover, printed copies of de-identified case report forms will be submitted to the rac at the kfsh&rc any time upon committee request and will be reviewed upon the receipt of the progress report by 4 june 2020 (the date specified originally upon irb approval of the study protocol). the following data will be collected: age, gender, weight, mode of mv at baseline, percentage of renal replacement therapy at baseline, lactate level at baseline, and severity of illness as estimated by sequential organ failure assessment (sofa) score and acute physiology and chronic health evaluation (apache ii) score, with higher scores indicating higher severity of illness [24] . moreover, we will collect icu type, baseline analgesics, sedatives, vasopressor requirements, and pre-deliric delirium risk score, which is a delirium prediction model specifically designed for adult critical care patients 24 h after icu admission. this model will be used to predict the factors that may influence delirium risk prior to randomization [25] . we will also collect rass, pain, and cam-icu scores at baseline and at 24 and 48 h post-randomization. the rass is a scale used to assess the depth of sedation on a scale of − 5 to + 4, with a negative value indicating deeper sedation and positive values indicating increased agitation [1] . the cam-icu is a valid and reliable delirium assessment tool. patients with a rass score of − 3 or lower will be excluded from cam-icu assessment, as they cannot participate in the exam [26] . we will calculate the modified clinical pulmonary infection score (cpis) to differentiate secretions caused by patients' underlying lung pathology (ventilator-associated pneumonia [vap]) vs ketamine-associated hypersalivation [27] . we will also record the proportion of eligible participants enrolled, rates of recruitment, protocol deviations, and aes. the sample size calculation associated with the specified (required) number of patients to be recruited is based on the study by buchheit et al. [9] . in their study, the median time from initiation of ketamine to extubation was 1.44 days (iqr 0.58-2.66). as time from initiation of ketamine to extubation is bounded below by zero, and assuming that the distribution is skewed toward larger times, a lognormal distribution was assumed to be appropriate for modeling such times. we additionally assumed that the distribution of times from intubation to extubation for patients who are not treated with ketamine is lognormal, with median 2.44 and iqr from 1.60 to 4.00. the hypothesis of interest is h0: m1 = m2 vs ha: m1 ≠ m2, where m1 is the median time for those treated with ketamine, and m2 is the median time for those not treated with ketamine. here the times are distributed with lognormal distributions, and the respective iqrs are 0.58-2.66 for ketamine-treated patients and 1.60-4.00 for those not treated with ketamine. a simulation analysis was carried out with 35 simulated patient times under each of the above two distributional scenarios, i.e., 35 intubation to extubation times under a lognormal of 1.44 and 0.58-2.66 (median and iqr) and 35 intubation to extubation times under a lognormal of 2.44 and 1.60-4.00 (median and iqr). this was followed by calculation of the level of significance by the wilcoxon rank sum test (i.e., the associated p value). by repeating this simulation 10,000 times, 80.24% of the simulations had a p value less than 0.05. this shows that the power of a design with 35 ketamine-treated and 35 non-ketaminetreated patients should (with at least 80% probability) demonstrate that the time from intubation to extubation is one day less for those treated with ketamine. it is recognized that non-compliance and dropouts may occur. hence, the study has been designed to recruit 40 ketamine-treated and 40 untreated subjects for analyses (i.e., total sample size 80). the median ventilator-free days will be calculated as calendar days with no ventilator support to day 28 post-randomization. participants who die before day 28 are assigned zero free days. data will be analyzed using the modified intention-to-treat principle and will comprise data from all patients who undergo randomization, with the exception of those who withdraw consent, have an unknown primary outcome, or are identified as ineligible after randomization. the shapiro-wilk test for normality will be used to assess the distribution of all outcome variables. chi-square and t tests (or wilcoxon rank sum) will be used to compare categorical data and continuous data, respectively. all data will be presented as median and iqr, if not normally distributed (or count and percentages, if categorical). univariate and multivariate regression analyses will be used to identify risk factors and predictors for delirium. statistically significant factors in the univariate analysis (≤ 0.05) will be included in the multivariate analysis. adjustments for the analysis will be accounted for with the bonferroni technique. a prespecified sub-group analysis of the primary outcome will be conducted on the following variables: age > 60 vs age < 60 sofa score > 10 vs < 10 apache ii > 20 vs < 20 ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (pf ratio > 150 vs pf ratio < 150) surgical vs medical admission. we will strive to obtain full data on every patient to allow an intention-to-treat analysis. if there is missing information as patients withdraw from the study before completion of the follow-up period, it will be handled in the normal fashion of survival analysis (censored observation). imputation (based on regression model) will be considered in case of incomplete information about key covariates. sensitivity analyses with such excluded patients will be conducted and compared with an imputed values model. each of the analyses will be redone to test each hypothesis and verify the robustness of the conclusion. statistical analyses will be performed using sas/ jmp, v.14.1 (sas institute, cary, nc, usa). the study statistician is blinded to the treatment allocation, and study investigators will remain blinded to the results until the conclusion of the study. the principal investigators will meet weekly to perform periodic internal audits of data accuracy, review enrollment rates, and oversee and coordinate the study in general. this will allow them to identify any protocol deviations and provide an opportunity for feedback to the other co-investigators. an independent rac at the kfsh&rc will serve as a safety monitoring committee which includes faculty with expertise in various disciplines engaged in human subjects' research from the hospital and research center, and also community members. consultants with special expertise might be invited to assist from time to time with complex issues. the committee will undertake periodic reviews at the discretion of the chair, and an expedited review is done for all serious unexpected adverse events (suaes), including death. the committee has the authority to suspend or halt recruitment if necessary. refer to supplementary file 2 for the form used to report suaes and death by the study investigators within 48 h of occurrence. all death cases reviewed so far have been due to the underlying disease, with participation in the trial not being a contributing factor. any clinically significant worsening in a study participant's condition based on clinical judgement compared to the baseline status at the time of randomization will be recorded as an ae in our progress report to be sent to the rac by 4 june 2020 (the date specified originally upon irb approval of the study protocol). this is applied whether or not the ae is considered to be related to the study treatment. in addition, this study is registered at the saudi food and drug authority (fda), which provides independent input regarding the safety of interventions. since this is an investigator-initiated, single-center, pilot, feasibility trial, periodic reviews are basically focused on monitoring safety. no formal interim analysis of efficacy will be undertaken due to possible small numbers that might preclude determination of a statistically significant difference in outcomes between the arms. no stopping rules or external independent data safety monitoring committee (dsmc) are specified. we believe the administration of sedative agents is standard of practice in the icu to minimize a patient's discomfort while on mv (see supplementary figure 1 : kfsh&rc new sedation protocol for adult icus). hence, the expected adverse effects will not exceed what is encountered during daily practice (e.g., benzodiazepine-associated delirium, opioid-induced constipation, hemodynamic instability associated with propofol and dexmedetomidine, ketamine-associated sympathetic stimulation " tachycardia and increase in blood pressure," and possible delirium). nonetheless, an external and independent dsmc will be considered moving forward to a multisite rct. as detailed in the patient information and consent form, any injury or complication occurring as a result of trial participation is to be reported to the study team, who will arrange all necessary medical treatment. trial disseminationthe trial registration and dissemination information is as follows: to the best of our knowledge, our pilot study is the first rct that compares adjunct low-dose ketamine infusion to standard of care alone in critically ill patients. it is conducted in a mixed icu cohort (medical, surgical, transplant, and oncology icu settings), focused on patient-centered outcomes as a primary outcome (duration of mv), and addresses the fact that most patients in the icu are sedated with a combination of drugs. randomization, blinded study participants and study statistician, and adherence to the modified intention-to-treat principle will limit potential sources of bias. another strength of this pilot study is the narrow randomization window (within 24 h post-intubation), which was chosen based on prior literature that showed early initiation of an intervention increases the ability of the intervention to influence the outcome, be more informative for clinicians, and have a greater power to detect an effect on important outcomes, such as duration of mechanical ventilation and long-term outcomes [16] [17] [18] . moreover, we elected to record the vasopressor requirements, cumulative sedatives and analgesics, number of patients within rass and pain score goals, and delirium incidence 48 h post-randomization to avoid the presence of confounders if measured > 48 h after ketamine infusion, similar to the study by groetzinger et al. [11] . a concern was raised about the under-dosing of ketamine compared to icu ketamine studies. various dosing regimens of ketamine continuous infusion for sedation are described in the literature. a recent systematic review described the existing data regarding ketamine dosing for adjunct sedation in small cohorts of primarily neurologically injured patients [12] . the included studies describe dosing regimens up to 103.3 μ g/kg/min (6.2 mg/kg/h), which is substantially higher than the doses prescribed in our cohort. as most patients in the review had a neurological injury, sedatives were administered to maintain deep sedation, and often with background benzodiazepine infusion or even barbiturate anesthesia [12] . on the other hand, groetzinger and colleagues used continuous infusion ketamine for adjunct sedation in a population of mechanically ventilated, critically ill adults targeting light sedation; ketamine was infused at a median starting dose of 1.6-4.2 μ g/kg/min (0.1-0.25 mg/kg/h) for a median of 2.8 days. the maximum doses of ketamine in individual patients experiencing adverse drug reactions (such as tachyarrhythmia) ranged from 2.08-20 μ g/kg/min (0.125 to 1.2 mg/kg/h), necessitating discontinuation of the infusion [11] . we aimed to describe our experience using ketamine as an adjunct low-dose sedative in an era that emphasizes light sedation in a complex, mechanically ventilated, critically ill population, specifically patients with medical illnesses, or following complicated surgical procedures. therefore, we chose in our pilot study the dosing regimen based on the rct cited by the 2018 padis guideline, which is comparable to the dosing regimen described in the study of groetzinger et al. we believe this represents the safest dose as an adjunct analgo-sedative agent to decrease the risk of side effects, i.e., delirium, hallucinations, and tachycardia, through its sympathetic stimulation [1, 3, 11] . limitations of our pilot study include the open-label design, as it has a process of multiple interventions related to the pain and sedation protocol. therefore, the icu treating team and the study investigators will know to which arm the study participants are randomized. moreover, we will not collect data on other pain medications such as morphine and hydromorphone, as those medications are rarely used, per the kfsh&rc adult sedation protocol, compared to fentanyl. another limitation is exclusion of patients in status asthmaticus or status epilepticus and patients placed on ecmo, as the dosing regimen of ketamine in those conditions is different than the regimen we used herein as an adjunct analgo-sedative agent. this may limit the external validity of this trial, although the population described in our cohort is relevant to many critically ill patients. since we were interested in describing ketamine infusions as part of a light sedation strategy, we have excluded patients for whom the rass goal is − 5, such as those receiving continuous infusion neuromuscular blockade. additionally, the safety profile described in our cohort is not generalizable to higher doses of ketamine used to achieve deep sedation. in conclusion, the findings of this pilot trial will contribute to a better understanding of adjunct low-dose ketamine infusion as an analgo-sedative agent and test the feasibility for a larger multicenter, randomized, double-blind, placebo-controlled trial with an adequate power to determine the effect of ketamine infusion as an analgo-sedative agent on clinical outcomes-mirroring other major sedation-related rcts [18, 23, [28] [29] [30] . future trials addressing cardiac assessment and hemodynamic metrics in a more protocolized way would be a great addition. for example, studies could assess metrics such as measurement of cardiac index (ci), stroke volume (sv), pulse pressure variation (ppv), and stroke volume variation (svv) estimated by arterial pulse pressure waveform analysis (e.g., with the vigileo monitor) at baseline (prerandomization) and at 24 and 48 h afterward (post-randomization), considering other potential confounders and adjunct interventions to evaluate whether these findings are direct consequences of ketamine or independent changes related to the severity of critical illness and the cumulative effect of adjunct interventions (i.e., antimicrobials, steroids, fluid administration, and blood products). lastly, it would be optimal to assess some patient-reported outcomes for those who developed an emergence reaction or delirium. the active engagement of patients and family members has been highlighted recently in the icu literature, and this would be a great addition to consider in a future multicenter trial through completing an icu diary or a survey 28 days post-icu discharge among icu survivors [31] . as of 10 october 2019, a total of 16 patients have been enrolled. we expect to complete the recruitment by 31 december 2020. the trial was first approved on 13 july 2019 (protocol v1) and opened to recruitment on 1 september 2019 (protocol v1). the protocol was amended on 3 september 2019 (protocol v2) requesting initial waiver of consent, as we faced difficulty with the patient enrollment and consenting prior to randomization due to inability to reach the legal surrogate (not answering the phone for verbal consent) or the emotional factor with the legal surrogate, especially during the first 24 h postintubation and icu admission. however, our research ethics committee mandated the informed consent prior to randomization. another protocol amendment (protocol v3) on 24 february 2020 reflected the clarifications that were made in the revised version. clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the icu continuous infusion ketamine for adjunctive sedation in medical intensive care unit patients: a case series the effects of small-dose ketamine on morphine consumption in surgical intensive care unit patients after major abdominal surgery low-dose ketamine in chronic critical illness continuous infusion ketamine for adjunctive analgosedation in mechanically ventilated, critically ill patients impact of ketamine use on adjunctive analgesic and sedative medications in critically ill trauma patients safety of sedation with ketamine in severe head injury patients: comparison with sufentanil comparison of ketamine-versus nonketamine-based sedation on delirium and coma in the intensive care unit impact of low-dose ketamine on the usage of continuous opioid infusion for the treatment of pain in adult mechanically ventilated patients in surgical intensive care units low doses of ketamine reduce delirium but not opiate consumption in mechanically ventilated and sedated icu patients: a randomized doubleblind control trial ketamine infusion for adjunct sedation in mechanically ventilated adults ketamine for analgosedation in the intensive care unit: a systematic review ketamine use in the intensive care unit role of ketamine in acute postoperative pain management: a narrative review consensus guidelines on the use of intravenous ketamine infusions for chronic pain from the american society of regional anesthesia and pain medicine, the american academy of pain medicine, and the american society of anesthesiologists early goaldirected sedation versus standard sedation in mechanically ventilated critically ill patients: a pilot study the spice iii study protocol and analysis plan: a randomized trial of early goal-directed sedation compared with standard care in mechanically ventilated patients early sedation with dexmedetomidine in critically ill patients (spice iii) ketamine continuous infusions in critically ill infants and children adverse events associated with ketamine for procedural sedation in adults comparing clinical outcomes between ketaminemidazolam and morphine-midazolam for continuous sedation in icu patients ketamine sedation in mechanically ventilated patients: a systematic review and metaanalysis reappraisal of ventilator-free days in critical care research the third international consensus definitions for sepsis and septic shock (sepsis-3) development and validation of pre-deliric (prediction of delirium in icu patients) delirium prediction model for intensive care patients: observational multicentre study psychometric properties of the arabic version of the confusion assessment method for the intensive care unit (cam-icu) diagnosing pneumonia during mechanical ventilation the clinical pulmonary infection score revisited dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the mends randomized controlled trial dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial (sedcom) nonpharmacologic interventions to prevent or mitigate adverse long-term outcomes among icu survivors: a systematic review and meta-analysis we thank the icu physicians, icu nurses, icu nurses' clinical educators, icu satellite pharmacists, and the pharmacy automation team at kfsh&rc for their support to this study. we are thankful to the saudi critical care trials group for providing feedback for the study proposal. we also thank the research staff, and the participants and their families. without their collective generosity, this trial would not have been possible. supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-4216-4. authors' contributions mb and ma conceived and designed the study and the analytical plan, drafted the manuscript, critically revised the manuscript for important intellectual content, and registered the trial at saudi fda, clinicaltrials.gov, and isrctn. dr. mb and dr. ma contributed equally as first authors, have full access to all of the data in the study, and take responsibility for the integrity of the data, study supervision, accuracy of the data analysis, and approval of the final version of the study protocol to be published. km acquired, analyzed, and interpreted the data, critically revised the manuscript for important intellectual content, and approved the final version to be published. mh acquired, analyzed, and interpreted the data, critically revised the manuscript for important intellectual content, and approved the final version to be published. ra, mr, ka, and ms acquired, analyzed, and interpreted the data and approved the final version to be published. ed participated in sample size calculation, analysis or interpretation of data, submission of the documents to the saudi fda, and approval of the final version to be published. we confirmed that the authorship followed the uniform requirements for manuscripts submitted to biomedical journals. all authors read and approved the final manuscript. research centre, p.o box 3354, riyadh 11211, tel: +966-11-464-7272 ext 32504. this trial is investigator-initiated, and all study authors are employees at king faisal specialist hospital and research center (kfsh&rc), which has not provided any research grant for this particular project. all authors are expected to volunteer their time and use local resources to conduct the study. the study drug ketamine is provided to the kfsh&rc pharmaceutical care division through hikma pharmaceuticals, which has no role in the design or conduct of the trial, analysis of the data, or writing or review of the manuscript. email: ora@kfshrc.edu.sa. all data in the study protocol are included in this published article and its supplementary information files. the study is conducted according to good clinical practice guidelines. the study protocol and informed consent were approved by the research ethics committee and clinical research committee at kfsh&rc with research advisory council number 2191 187. once an eligible patient is identified, study investigators start the consenting process to explain the objectives of the trial and its potential risks and benefits to the patient's surrogate decision-maker. a verbal consent from a guardian/next of kin over the phone is considered to allow randomization and initiation of timely intervention when written authorization cannot be secured in sufficient time (within 24 h of intubation). verbal consent is documented in medical records to indicate the research subject's acceptance to participate in the study. a prospective written consent is obtained thereafter from the patient (if extubated) or the patient's guardian/next of kin once they become available. not applicable. the authors declare that they have no competing interests. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-030531-4uucx9ss authors: randremanana, rindra vatosoa; raberahona, mihaja; randria, mamy jean de dieu; rajerison, minoarisoa; andrianaivoarimanana, voahangy; legrand, agathe; rasoanaivo, tsinjo fehizoro; randriamparany, ravaka; mayouya-gamana, théodora; mangahasimbola, reziky; bourner, josie; salam, alex; gillesen, annelies; edwards, tansy; schoenhals, matthieu; baril, laurence; horby, peter; olliaro, piero title: an open-label, randomized, non-inferiority trial of the efficacy and safety of ciprofloxacin versus streptomycin + ciprofloxacin in the treatment of bubonic plague (imasoy): study protocol for a randomized control trial date: 2020-08-17 journal: trials doi: 10.1186/s13063-020-04642-2 sha: doc_id: 30531 cord_uid: 4uucx9ss background: bubonic plague is the primary manifestation of infection with yersinia pestis, accounting for 90% of all plague cases and with 75% of global cases reported in madagascar. all drugs in use for treating plague are registered based on experimental data and anecdotal evidence, and no regimen currently recommended is supported by a randomized clinical trial. the imasoy trial intends to fill this knowledge gap by comparing two 10-day regimens included in the national guidelines in madagascar. the primary objective of the trial is to test the hypothesis that ciprofloxacin monotherapy is non-inferior to streptomycin followed by ciprofloxacin for the treatment of bubonic plague, thus avoiding the need for injectable, potentially toxic, aminoglycosides. methods: a two-arm parallel-group randomized control trial will be conducted across peripheral health centres in madagascar in five districts. males and non-pregnant females of all ages with suspected bubonic or pneumonic plague will be recruited over the course of three plague ‘seasons’. the primary endpoint of the trial is to assess the proportion of patients with bubonic plague who have a therapeutic response to treatment (defined as alive, resolution of fever, 25% reduction in the size of measurable buboes, has not received an alternative treatment and no clinical decision to continue antibiotics) as assessed on day 11. discussion: if successful, the trial has the potential to inform the standard of care guidelines not just in madagascar but in other countries afflicted by plague. the trial is currently ongoing and expected to complete recruitment in 2022. trial registration: clinicaltrials.gov nct04110340. registered on 1 october 2019 plague is caused by the gram-negative bacteria yersinia pestis. there are three main clinical forms in which plague can manifest, sometimes with overlapping clinical syndromes: bubonic plague, septicaemic plague (primary or secondary) and pneumonic plague (primary or secondary) [1] . bubonic plague is the most common clinical form and is characterized by the rapid onset of fever and tender and painful lymphadenopathy. it accounts for over 90% of plague cases [1] . septicaemic plague is characterized by non-specific symptoms, as for septicaemia in general [1] . pneumonic plague presents with rapid onset of fever and respiratory symptoms, with haemoptysis being a cardinal feature [1] . plague is primarily present in africa, although the usa and countries in asia and south america are also affected. the incidence of plague continues to decrease (from 2683 cases notified to the who in 2008 to 243 in 2018) and geographical spread to shrink (98% of reported cases currently from just madagascar and the democratic republic of congo (drc)) [2] . however, the reservoir and conditions for transmission are still present in many areas of the world, and there is a risk of outbreaks when plague hits densely populated areas, as in the 2017 large urban outbreak of predominantly pneumonic plague in madagascar, with over 2400 suspected cases [3] . in the pre-antibiotic era, the case fatality rate (cfr) of plague was > 70% [4] . antibiotics have significantly reduced mortality: for the cases notified to who during 2010-2018 cfr averaged 17% [2] . during the 2017-2018 plague outbreak in madagascar, the cfr of confirmed pneumonic plague was 25% and bubonic plague 24% [3] . until july 2018, the 1st-line treatment regimen for bubonic plague in madagascar was streptomycin (days 1 to 5) followed by cotrimoxazole (days 3 to 8). following the 2017 epidemic, an after action review was conducted and treatment guidelines for bubonic plague were modified to include, for adults, either streptomycin intramuscularly 1 g (except pregnant women) or gentamicin 2.5 mg/kg twice daily for 3 days, followed by ciprofloxacin 500 mg twice daily for an additional 7 days or ciprofloxacin alone at 500 mg twice daily for 10 days. intravenous ciprofloxacin at a dose of 400 mg every 12 h can be used if the oral route is not possible. treatment options in children are now either oral ciprofloxacin 15 mg/kg twice daily for 10 days or, if oral administration is not initially possible, streptomycin 15 mg/kg every 12 h intramuscularly for 3 days followed by ciprofloxacin 15 mg/kg twice daily for an additional 7 days. the first-line treatment regimen for pneumonic plague in adults is streptomycin 1 g intramuscularly twice daily for 5 days combined with ciprofloxacin 500 mg orally twice daily for 10 days, and for children, intravenous gentamicin at 2.5 mg/kg every 12 h for 5 days (or streptomycin) combined with oral ciprofloxacin at 15 mg/kg every 12 h for 10 days (with the possibility of intravenous ciprofloxacin at 15 mg/kg every 12 h if the oral route is not available). the maximum dose for ciprofloxacin is 500 mg per oral dose and 400 mg per intravenous dose for children. streptomycin alone or in other combination therapies is also the treatment of choice in other countries, including the drc and peru. the evidence base for the current treatment regimens for plague is weak, and none is supported by a randomized clinical trial (rct). two randomized control trials have previously attempted to improve on or contribute to a better evidence base for current plague treatment regimens [5, 6] . however, neither trial was successful nor included children under 8 years of age, who constitute a significant proportion of the population affected by plague. treatment recommendations are based on animal models, case reports, case series and a trial of doxycycline versus gentamicin [5] . all drugs approved for treating plague by the the united states food and drug administration (us fda) (streptomycin, tetracyclines and the fluoroquinolones ciprofloxacin, levofloxacin and moxifloxacin) are registered based on the 'animal efficacy rule', in the absence of clinical data [7] . political instability and practical difficulties related to highly dispersed cases in rural areas have been the major obstacles to conducting treatment trials of plague. the main issue with current regimens in madagascar is the use of aminoglycosides-with the need for injections, class toxicity and need for monitoring of renal and auditory functions, which is not routinely available in most low-and middle-income countries, and streptomycin cost and stock-outs. ciprofloxacin is cheaper, more readily available in lowand middle-income countries, has greater ease of administration and there is no need for biochemical or drug monitoring. there is also no reason to believe that there is a difference in effectiveness. these reasons would likely result in ciprofloxacin being the first-line choice for the treatment of plague should it be shown to be effective. the primary objective of this trial is to test the hypothesis that ciprofloxacin monotherapy given (orally, or for subjects who cannot take oral medications intravenously or in combination) for 10 days is noninferior to streptomycin (given on days 1-3) followed by ciprofloxacin (given on days [4] [5] [6] [7] [8] [9] [10] for the treatment of bubonic plague. the regimens are respectively thirdand first-line treatments as per the national plague treatment guidelines in madagascar. the secondary objective is to collect data on the effectiveness of ciprofloxacin in the treatment of pneumonic plague, although the trial is not able to formally assess the non-inferiority of ciprofloxacin monotherapy compared to streptomycin and ciprofloxacin combination therapy in pneumonic plague, considering the operational and practical complexities of a plague rct, the study also has additional exploratory objectives to optimize investments: to evaluate the level and kinetics of anti-y. pestis antibodies in bubonic and pneumonic plague during treatment and follow-up, to compare different methods for detection of anti-y. pestis antibodies, to measure the performance of qpcr for plague diagnosis and to allow for the evaluation of new rapid tests that may become available. this is an individually randomized two-group parallel arm control trial with a 1:1 ratio. patients will be randomized to receive either streptomycin + ciprofloxacin or ciprofloxacin alone. we are using a non-inferiority design since the overall cure rate for bubonic plague without septicaemia with streptomycin is expected to be 90%. as a result, demonstrating superiority would be unnecessary and impractical given the sample size that would be required. our aim is therefore to demonstrate that ciprofloxacin alone is not more than 15% inferior to streptomycin followed by ciprofloxacin (15% is the non-inferiority margin in our study, meaning that the lower bound of the confidence interval around the risk difference in the success rates of streptomycin + ciprofloxacin and ciprofloxacin alone must not include 15%). the trial is powered for bubonic plague, although we will recruit patients with pneumonic plague as well. probable and confirmed cases are defined as: probable case: rapid diagnostic test (rdt) or qpcr or serology (anti-f1 igg elisa) is positive but without evidence of seroconversion or a fourfold increase in antibody titre. confirmed case: rdt and qpcr are positive, or culture is positive, or there has been a seroconversion or a fourfold increase in antibody titre on two separate serological samples (either between d1 and d11, between d11 and d21 or between d1 and d21). we will recruit patients with clinical suspicion of bubonic plague, but the size of our sample is powered based on an intention to treat infected patient sample size of 190, where 'infected' is defined as a 'confirmed' or 'probable' case of bubonic plague. as a result, the total number of patients to be enrolled will be higher than 190. we estimate that we will need to recruit approximately 600 patients with bubonic plague to achieve a sample size of 190 confirmed/probable bubonic plague patients. however, to mitigate risks of being under-powered, we will recruit for three full seasons (2019-2022) with a minimum target of 190 confirmed/probable cases, 95 patients in each arm. should we achieve the target of 190 confirmed/ probable bubonic plague cases before the end of the third season (2019-2022), we will nevertheless continue to recruit until the end of the season to retain power in the event the observed treatment success rates differ from those expected, and to allow us to increase precision. whilst we will also recruit and collect data on patients with pneumonic plague, it is highly unlikely that we will have the power to complete a non-inferiority trial for ciprofloxacin monotherapy for pneumonic plague patients. for example, with a case fatality rate of 20-25%, we would need a sample size of approximately 400 patients with probable/confirmed pneumonic plague for a non-inferiority margin of 15%, which is unrealistic. recruitment is expected to last 3 years and will take place during each 'plague season' (the annual high transmission period of plague, which starts at the beginning of august and runs until the following march). the study will enrol males and non-pregnant females of any age with suspected bubonic or pneumonic plague. study setting {9} study setting the trial will take place in up to five pre-identified districts in madagascar. madagascar reports more plague cases per year than any other country with an average number of confirmed/probable cases per year of 387 [8] . recruitment is planned to take place in 50 health centres (primary health centres (centres de santé de base, csb) and district hospitals) in five districts. recruiting districts and sites have been selected based on their incidence of plague (as reported to ipm) and also for logistical reasons. however, the trial may be carried out in further districts or sites depending on the real-time incidence of suspected cases of plague during the study period. the majority of plague patients are treated at the csb level. in general, csbs do not have a laboratory, so sites perform an rdt to obtain a preliminary diagnosis and then send further samples to ipm for confirmation where a second rdt, qpcr and culture are routinely performed. patients of any age recent onset (< 10 days) of fever (uncorrected axillary temperature ≥ 37.5°c) or history of fever one or more buboes (tender lymph node swelling) residence or travel to a plague endemic or outbreak area in madagascar within 14 days of the onset of symptoms patients identified as clinically suspected of plague by health personnel (doctors or paramedics) patients of any age recent onset (< 7 days) of fever (uncorrected axillary temperature ≥ 37.5°c) or history of fever cough tachypnoea (respiratory rate > 24 in adults and agespecific in children) epidemiological link with a confirmed or probable case of primary or secondary pneumonic plague within 7 days of onset of symptoms a small proportion of patients with bubonic plague will also develop pneumonic plague. these patients will be randomized to receive pneumonic plague therapy. for a patient to be considered to have mixed bubonic and pneumonic plague, they must have developed cough and dyspnoea after the onset of the bubo. known allergy to aminoglycosides or fluoroquinolones tendinitis myasthenia gravis theophylline or warfarin use already treated for bubonic or pneumonic plague in the preceding 3 months women who report being pregnant given that streptomycin is an fda class d drug, women who report being pregnant will not be randomized into the trial but will be treated outside the trial according to the national guidelines. lactating women can safely be treated with streptomycin as streptomycin poses minimal risk to the infant when used during breastfeeding and will therefore be randomized into the trial. all eligible patients will be offered the opportunity to participate in the study. patient information sheets, consent and assent forms will be available in relevant written local languages. written informed consent to participate will be required from all participants or their representatives and will be requested by local study staff, who are qualified, trained and authorized to do so by the principal investigator. patients are fully informed about the use of biological specimens and their data in the patient information sheet, including lay descriptions of the procedures for collecting samples and details about data and sample storage. both treatment regimens tested are provided for by the national guidelines. there are several reasons why streptomycin is a suboptimal therapeutic agent for plague including global stock shortages, the requirement for parenteral administration and severe toxicity. in vitro assays suggest that ciprofloxacin has comparable efficacy to streptomycin and is superior to doxycycline or gentamicin for the killing of intracellular y. pestis [6] . studies in non-human primates of pneumonic and bubonic plague have also shown high therapeutic efficacy of ciprofloxacin, equivalent to streptomycin [9, 10] . ciprofloxacin also offers the advantage of the possibility of a switch from intravenous to oral treatment if clinically appropriate, does not require drug level or renal function monitoring, has fewer and less severe side effects, it is classed by the us fda as pregnancy category c (whereas other treatment alternatives are category d), has greater global availability and is cheaper. unlike other treatment alternatives, ciprofloxacin can be administered to children. dosing schedule in bubonic plague adults: 500 mg orally twice daily (or 400 mg iv twice daily for those who cannot take oral medication) for 10 days. children: 15 mg/kg twice daily (max 500 mg per dose) orally (or 10 mg/kg iv twice daily for those who cannot take oral-maximum dose 400 mg) for 10 days. patients who begin intravenous therapy may switch to oral administration once they are able to swallow or once deemed clinically appropriate by the treating physician. adults: streptomycin 1 g twice daily for 3 days, followed by ciprofloxacin 500 mg orally twice daily (or ciprofloxacin 400 mg twice daily by iv for those who cannot take it orally) for an additional 7 days. children: streptomycin 15 mg/kg twice daily for three days followed by ciprofloxacin 15 mg/kg twice daily (max 500 mg per dose) orally (or 10 mg/kg iv twice daily for those who cannot take oral-maximum dose 400 mg) for 7 additional days. patients who start taking intravenous ciprofloxacin may switch to oral administration once they are able to swallow or once deemed clinically appropriate by the treating physician. adults: 500 mg orally twice daily (or 400 mg iv twice daily for those who cannot take oral medication) for 10 days. children: 15 mg/kg twice daily (max 500 mg per dose) orally (or 10 mg/kg iv twice daily for those who cannot take oral-maximum dose 400 mg) for 10 days. patients who begin intravenous therapy may switch to oral administration once they are able to swallow or once deemed clinically appropriate by the treating physician. adults: streptomycin 1 g twice daily for 5 days with ciprofloxacin 500 mg orally twice daily (or ciprofloxacin 400 mg twice daily iv for those who cannot take it orally) for 10 days. children: streptomycin 15 mg/kg twice daily for 5 days with ciprofloxacin 15 mg/kg twice daily (max 500 mg per dose) orally (or 10 mg/kg iv twice daily for those who cannot take it orally-maximum dose 400 mg) for 10 days. this is the alternative treatment proposed by the ministry of public health since the 2018-2019 plague season. patients who start taking intravenous ciprofloxacin may switch to oral administration once they are able to swallow or once deemed clinically appropriate by the treating physician. streptomycin is administered intramuscularly to all patients in the control group. ciprofloxacin is administered orally, except for patients with the following manifestations: vomiting unable to swallow unconscious systolic blood pressure < 90 mmhg any other conditions or situations for which the physician decides that intravenous treatment is indicated ciprofloxacin: doses will be administered morning and evening. streptomycin: doses will be administered morning and evening. the study drugs will be administered for a total of 10 days. after 10 days, the decision whether to continue therapy will be at the treating physician's discretion. we are using 10 days of therapy in both the ciprofloxacin arm and streptomycin and ciprofloxacin arm as this is the current standard duration of plague treatment in madagascar. to date, the only rct in plague used 7 days of therapy (gentamicin versus doxycycline) in both groups. criteria for discontinuing or modifying allocated interventions {11b} if, for any reason, a dose of the study drug is not administered at the scheduled time, it may be administered later, but not more than 6 h after the scheduled time of administration. no dose adjustment is planned. the trial will be co-managed by ipm who will deploy a clinical research associate and two clinical study nurse to each district to assist with the recruitment, trial procedures and data entry. these members of staff will be based in the districts for the duration of each season. before activation, site investigators will receive training on the identification of plague patients and the study protocol. after activation, the site investigators will be responsible for patient management alongside the clinical study nurse. to optimize patient compliance, community health workers (chws) in each district will be trained to identify cases of plague based on community case definition as per the national guideline, refer patients to the local csb i/ii, perform treatment visits to patient homes and complete the treatment record for each home-based visit. at the time of discharge from the facility, patients will also be equipped with a mobile phone, as follow-up visits on d11 and d21, and possibly m3 will require a return visit to the treating csb. at the beginning of each new plague season, all site staff will be retrained on the trial protocol and reinitiated to the trial. this will reinforce the protocol following the annual recruitment suspension and ensure that, due to high staff turnover at the csbs, any new staff members receive the same comprehensive training as those who were trained at the original initiation visit. a monitoring plan has been developed to ensure regular reviews of trial data and site compliance with the protocol. these reviews will be completed within 72 h of each of the first five patients being recruited at each site, annually at the end of each plague season and on the identification of persistent or serious protocol violations and serious breaches. the trial operations committee (toc) will also meet on a weekly basis to review recruitment and compliance and discuss any other issues affecting the trial. the trial has also appointed a data safety monitoring board (dsmb) and trial steering committee, who will meet regularly to discuss the management of the trial. other treatments, including the administration of fluids and organ support, will be at the discretion of the treating clinician. post-trial care following their exit from the trial, patients will return to their standard care pathway. the university of oxford, as study sponsor, has arranged appropriate insurances to provide for the university's responsibilities to research subjects and to cover the legal liabilities of the university to those engaged by the university in the performance of this research. the proportion of patients with bubonic plague with a therapeutic response (assessed on d11). therapeutic response is defined as follows for subjects with a visible and measurable bubo: resolution of fever (uncorrected axillary temperature < 37.5°c) a ≥ 25% decrease in bubo size (in the case of multiple buboes, the largest bubo) has not received alternative treatment for plague no clinical decision to continue anti-plague antibiotics beyond day 10 for patients with small buboes that are palpable but not measurable: absence of fever (uncorrected axillary temperature < 37.5°c) bubo has not enlarged has not received alternative treatment for plague no clinical decision to continue anti-plague antibiotics beyond day 10 proportion of patients without fever (uncorrected axillary temperature < 37.5°c) at d4 proportion of patients with a pain score < 3 at d4 proportion of patients with a pain score < 3 at d11 mean % change in bubo size at d4 mean % change in bubo size at d11 proportion of patients experiencing a serious adverse event on or before d4 proportion of patients experiencing a serious adverse event on or before d11 proportion of patients experiencing a serious adverse event on or before d21 proportion of patients who are fully adherent to the study treatment schedule proportion of patients with a therapeutic response at d11. therapeutic response is defined as follows: alive resolution of fever (uncorrected axillary temperature < 37.5°c) resolution of tachypnoea (rr < 24 in adults, but age-specific in children) proportion of patients without fever (uncorrected axillary temperature < 37.5°c) at d4 proportion of patients with tachnypnoea resolution (rr < 24 in adults, but age-specific in children) at d4 proportion of patients experiencing a serious adverse event on or before d4 proportion of patients experiencing a serious adverse event on or before d11 proportion of patients experiencing a serious adverse event on or before d21 proportion of patients who fully adhere to the study treatment schedule the participant timeline is described in the flow chart (fig. 1) . the schedules of biological procedures, assessments and samples are summarized in the following tables (tables 1 and 2) . the conduct of the study is described in fig. 2 . the maximum volume of blood to be collected during the entire duration of the study (3 months) for confirmed cases with a positive serology at d21 will be 8 ml for children and 16 ml for adults. assuming that 90% of individuals receiving streptomycin plus ciprofloxacin (control treatment) meet the primary endpoint definition of therapeutic response on day 11, 190 confirmed/probable bubonic plague patients (95 per group) would be required to have 90% power to demonstrate the non-inferiority of ciprofloxacin treatment compared to streptomycin plus ciprofloxacin, with a 15% non-inferiority margin and a one-sided confidence interval of 2.5%. this calculation takes into account a 10% loss to follow-up rate by the end of treatment. in total, approximately 600 suspect patients will have to be recruited to obtain a sample size of 190 confirmed/probable patients. table 3 shows the total sample sizes (both arms) for confirmed/probable bubonic cases to demonstrate noninferiority with 90% power, 2.5% one-sided test and assuming 10% loss to follow up, based on treatment success in the streptomycin and ciprofloxacin group and the non-inferiority margin. sites will be geographically spread throughout preidentified districts which report a high incidence of plague. further districts may be included later in the trial in the event that they also report a high incidence of plague. whilst it is the responsibility of site medical staff to assess eligibility and enrol patients, the clinical study nurse, who will be based within the district, will review and verify the eligibility of each patient. community health workers, who will cover a wider geographical area within the districts and reach more remote communities, will also be trained on the protocol and refer suspected cases of plague to the local csbs. outreach teams will disseminate health promotion messages to local health authorities and communities about plague (i.e. signs and symptoms), as well as the background and objectives of the trial. community health workers will also raise awareness about going to health centres in the event of suspected plague. a social science component will address the practical aspects and uptake of the trial that may be affected by the perception of the trial design by both heath care professionals and patients. bubonic or pneumonic plague patients will be randomized using a computer-generated randomization sequence generated from the master list, stratified by health facility and clinical form of the disease (bubonic or pneumonic plague). the allocation sequence was compiled in stata in a way that is unpredictable and unreproducible. a copy of the stata randomization code file used to compile the list can be requested from the trial statistician. the trial statistician will have access and be responsible for the generation and quality assurance of the randomization list. this also includes any changes and/or extensions to the trial statistician has generated the allocation sequence. the doctor in-charge at the csb will confirm the eligibility of patients with the support of the clinical study nurse. to randomize patients, the doctor in-charge will call the clinical research associate who will randomize the patient on the site's behalf, informing the site of the treatment allocation over the phone. contingency plans have been put in place to ensure randomization can take place in the event of internet or mobile signal outage. blinding of patients and the trial team to treatment allocation will not be possible due to the different administration routes of the treatments. not applicable-this is not a blinded trial. data will be collected on a paper crf and then transferred on to a redcap database for assessment. automatic validations on redcap will assess data for completeness and accuracy. a thorough assessment of data accuracy will be performed via regular monitoring activities with a focus on primary endpoint data and safety data, as described in the trial's monitoring plan. to validate the methods used to achieve the primary endpoint (% decrease in bubo size), a pilot study and training exercise were conducted ahead of activation in which multiple bubo (real and artificial) measurements were taken using digital callipers (and ultrasound during the pilot). the data were used to assess the concordance of measurements being taken by independent observers. the percentage difference between the sum of the longest and shortest axes of measurements taken by two different clinical study nurse was calculated with an acceptable margin of 25%. the results showed there was less than 25% difference between each measurement. patients will be provided with a mobile phone upon discharge from the treating centre to optimize retention adverse events x x x x x x bubo size and pain score x x x x assessments will be done within 24 h of enrolment, depending on the time of admission m3 3 months after inclusion during follow-up. community health workers will also assist with reminding patients about their upcoming follow-up visits. if a patient chooses to withdraw from trial treatment (or the treating clinician believes this is in the best interest of the patient), the patient will continue to receive the standard of care treatment at the discretion of their treating clinician, regardless of the treatment arm to which the patient was randomized. the patient will remain within the trial for the purpose of follow-up, data collection, monitoring and data analysis. healthcare personnel should explain the importance of allowing existing data to be used, as well as the importance of remaining within the trial for follow-up data collection. if it is not possible to collect further data from the patient at the scheduled trial visits, routine data should be collected via the patients' medical records. if a patient withdraws their consent to participate in the trial, data and sample collection will cease and only data up to the point of withdrawal will be used for analysis. all data will be recorded on a paper crf by clinical study nurses at each study site using a combination of data directly from patients, patient records and laboratory results. the clinical study nurses will then transfer the data from the paper crf to a redcap database (version 8.5.17 ), which will be located centrally at ipm with restricted access. data queries will be automatically generated by redcap and transferred to the operational teams in the districts for data quality monitoring as the study progresses. data monitoring will be conducted on a regular basis as defined in the monitoring plan. the final database will be transferred to oxford university. a statistical analysis plan will be prepared prior to the receipt of any data by the trial statistician. the management, reporting processes and data storage within this trial will comply with the requirements of european directive (reference 2016/679, "gdpr directive") on data protection which is translated into english law by the "data protection act" of may 2018, the good clinical practices of the gcp-ich, and cioms. all the systems used for data management comply with the gcp-ich and cioms recommendations as well as the european directive (reference 2016/679, "gdpr directive") on the protection of personal data, which is translated into english law by the "data protection act" of may 2018. trial staff will ensure that the participants' anonymity is maintained. all trial documents will be labelled only with a trial identification number. trial samples will be labelled only with a trial id. routine bubo and sputum samples, which will be analyzed as part of the trial, will be transferred to ipm as per the standard transfer process. the routine samples taken from trial patients will be labelled with a collection label which will not contain a patient trial identifier. a separate letter will be sent to ipm containing anonymised collection information and the patient's trial id. this will be used to ensure the results of sample testing from the lab are collected for the trial without compromising the patient's anonymity. for the purpose of ensuring data integrity and to facilitate quality assurance, study records will be linked to clinic files, which include the patient's name and other identifying information. participants' names will be recorded confidentially at site in a protected master list at the time of enrolment to allow for their identification at follow-up visits. the master list will not be shared with any other parties involved or not involved in the trial. all trial data will be stored in a secure database only accessible to trial staff. only members of the trial team who have completed appropriate data protection training will have access to the password-protected computer where trial data is stored. study sponsors and health authorities will be given controlled access for the purpose of audit. after the conclusion of the project, data will be removed from the computers and stored in a secure location. any scientific publications or reports will not identify any patient by name or initials. plans for collection, laboratory evaluation and storage of biological specimens for genetic or molecular analysis in this trial/future use {33} aliquots of blood, bubo aspirates and sputum samples will be stored initially at the site and then transported to ipm. sample custody will be maintained by the investigators, and decisions regarding the use and transfer of samples to the research laboratory will be made by the toc. biological research samples will be stored indefinitely, and approval from the sponsor and/or ethics committees, as appropriate, will be sought prior to destruction. the bubo will be aspirated, and a rdt for plague will be performed on site. this rdt for the detection of the f1 antigen of y. pestis is manufactured by ipm. the test has been used routinely over the past decade and has been validated for bubonic plague. site staff, clinical research associates and clinical study nurses will be trained on the use and interpretation of the rdt before the start of the study and during annual retraining. the remaining bubo aspirate will be stored in cary blair transport medium, packed according to the required safety level using the materials already provided (triple packaging), then sent to the cpl at ipm for a second rdt analysis as well as for molecular and bacteriological diagnosis. molecular diagnosis will first be performed by real-time pcr (qpcr) targeting 2 fragments of the pla and caf-1 genes of y. pestis, and only samples with inconclusive results will be confirmed by conventional pcr (cpcr) targeting 3 genes pla, caf-1 and inv1100. bacteriology will be done with direct culture and amplification in mice followed by biochemical identification of the suspected strain by api 20e and by bacteriophage lysis test, then antibiotic susceptibility testing of each y. pestis isolated strain according to the kirby bauer method interpreted according to the clsi reference. sputum samples will not be tested on site with rdt but will be sent directly to the cpl. biological results will be sent back to the physician responsible for the patient. a malaria rdt will be performed on all patients at admission. a 4-ml venous blood sample will be taken at admission (d1), d11 and d21 for plague serology (for children, a 2-ml venous blood sample will be taken at these time points). in addition, for subjects with positive serology at d21, serological follow-up will be carried out at 3 months (m3) after their inclusion. two types of serological techniques will be performed: serology by immuno-enzymatic assay method (elisa, anti-f1 antibodies, igg) which is validated and will be performed at the cpl, and serological analysis by xmap-luminex multiplex technique (magpix) to simultaneously detect antibodies (igm and igg) directed against several y. pestis antigens will be performed at the immunology of infectious diseases unit (imi) at ipm. a serological test (on magnetic beads, xmap-luminex) to detect and quantify the f1 circulating antigen of y. pestis will also be performed. only anti-f1 igg elisa technique will be considered for case classification. statistical methods for primary and secondary outcomes {20a} primary endpoint analysis the final classification of cases will take into account all clinical and biological data in accordance with who recommendations adapted in 2017 with the introduction of qpcr as a diagnostic tool [3, 11] . the data will be analyzed using four analysis populations: (i) intention to treat (itt), (ii) intention to treat infected (itti), (iii) per-protocol (pp) and (iv) perprotocol infected (ppi). intention to treat infected (itti) will be the primary analysis population. an infected patient is a confirmed or probable case. a case is probable if the rdt or qpcr or serology (anti-f1 igg elisa) is positive but without evidence of seroconversion or a fourfold increase in antibody titre. a case is confirmed if the rdt and qpcr are positive or if the culture is positive or if there has been a seroconversion or a fourfold increase in antibody titre on two separate serological samples (either between d1 and d11, between d11 and d21 or between d1 and d21). the criteria for exclusion from the per-protocol analysis population will be specified in advance in the statistical analysis plan (sap). the proportion of patients who meet the pre-established definition of therapeutic response in the streptomycin plus ciprofloxacin group will be subtracted from the proportion of patients who meet the pre-established definition of therapeutic response in the ciprofloxacin group. a positive difference in proportions would imply a higher response in patients treated with ciprofloxacin, compared to streptomycin plus ciprofloxacin, and a negative difference would imply a lower response in patients treated with ciprofloxacin. if the lower limit of the one-sided 2.5% confidence interval (ci) around the difference in proportions is not less than − 0.15, ciprofloxacin will be considered non-inferior to streptomycin plus ciprofloxacin. descriptive summaries of the data will be provided by randomization arm for the pre-specified secondary outcomes. the data will be summarized by randomization arm using the mean (95% cl) and median (interval) for continuous or discrete data and raw data with percentages and 95% cis for binary variables. the average time to resolution of fever and pain at the bubo site will also be summarized. no formal interim analysis is planned. it is unlikely that the trial can be stopped prematurely, as a smaller sample will not provide the precision required to demonstrate non-inferiority within the pre-specified margin. no additional analyses are planned. methods in analysis to handle protocol non-adherence and any statistical methods to handle missing data {20c} missing data handling: primary endpoint if a patient has had a resolution of fever and shows a ≥ 25% reduction in bubo size on or after day 4, but is lost for follow-up before day 11, he or she will be considered to have had a therapeutic response. any deviations from the protocol will be fully documented on a protocol deviation form that will be sent to the sponsor and stored in the trial master file and on site in the study site file. plans to give access to the full protocol, participant-level data and statistical code {31c} there are currently no plans to grant public access to the full protocol, participant-level dataset or the statistical code. composition of the coordinating centre and trial steering committee {5d} ipm will jointly coordinate the trial with the sponsor, the university of oxford. as well as a central trial coordination team to coordinate the day-to-day activities of the trial, ipm will deploy one clinical research associate and two clinical study nurses to each district who will assist the sites with the recruitment, data collection and conduct monitoring activities. ipm will also be primarily responsible for data management but supported by the university of oxford. the university of oxford will coordinate the sponsor activities, coordinate the trial committees and provide day-to-day management and oversight of the trial. the toc is coordinated by the university of oxford and is composed of members from each of the study partners to review the operational management of the trial and discuss any urgent matters related to trial conduct as and when they arise. the group meets on a weekly basis to discuss study progress. the trial steering committee provides overall supervision for the trial on behalf of the trial sponsor and to ensure that the study/trial is conducted according to the guidelines for good clinical practice (gcp) and all relevant regulations and local policies. a data safety monitoring board has also been established to maintain oversight of patient safety and data integrity within the trial. composition of the data monitoring committee, its role and reporting structure {21a} an independent data safety monitoring board (dsmb) has been established to safeguard the interests of trial participants, to assess the safety of the interventions during the trial and to assist and advise the principal investigator (pi) so as to protect the validity and credibility of the trial. the dsmb will meet remotely (1) upon the opening of the trial, (2) at the end of each plague season and (3) streptomycin and ciprofloxacin are approved drugs with well-established safety profiles. serious adverse events/ serious adverse reactions (saes/sars) and suspected unexpected serious adverse reactions (susars) will be reported in accordance with the international guidelines and applicable national legislation. all adverse events (aes) observed or reported by the patient should be recorded on the ae form within the crf. in the event of an adverse event or reaction, the investigator is responsible for providing an appropriate medical response, providing a causality assessment and monitoring the progress of the ae until it has resolved. in the event that an adverse event is deemed serious, according to the international definition (ich), it should be notified immediately to ipm via the sae report form within 48 h of the site becoming aware of the event. newly arising saes must be reported from the point of consent until d21. all saes must be followed up by the site until resolution (including when resolution occurs after d21). the following events, which are either classified as treatment evaluation criteria or inclusion criteria, are exempt from reporting as an sae: respiratory symptoms (cough, tachypnea, haemotysis) intestinal symptoms (diarrhoea, vomiting) fever bubo pain at bubo's site in addition, the following circumstances should not be notified to the sponsor: medical/surgical/hospital procedure planned before inclusion a condition present before inclusion or discovered at inclusion (e.g. malaria discovered at inclusion and requiring hospitalization) all saes/sars reported to ipm will be notified to the sponsor within one business day and will be reviewed and evaluated by two clinical reviewers. if the reviewers have concerns about the saes submitted, an emergency meeting of the dsmb and the toc will be convened to discuss the management of the sae and the potential impact on the trial. all susars will be reported to the centre national de pharmacovigilance in madagascar within 7 days for fatal or life-threatening reports and within 15 days for other serious, unexpected sars for all initial reports. none. plans for communicating important protocol amendments to relevant parties (e.g. trial participants, ethical committees) {25} all protocol amendments will be discussed by the toc which includes members from each of the study partners ahead of submission to the respective ethics committees. it is the responsibility of each institution to obtain their own ethical approvals. only once all ethical approvals have been obtained will the amendment be implemented. it will be the responsibility of ipm to disseminate the changes to the protocol to participating sites. the principal publication of the study will be in the name of the investigators with full credit assigned to all collaborating investigators, research coordinators and institutions. oral or written communications will acknowledge all trial stakeholders, either in the list of authors or in the acknowledgements, depending on their respective contributions to the trial and the presentations made. a drafting committee will be formed at the time of data analysis. the order of authors at publication will be equally contributed, by the importance of contribution or in alphabetical order. results from the trial will be published in open-access journals, and the data will be available for sharing. conducting clinical trials of plague is operationally challenging, mostly because cases occur in rural places with difficult access to health facilities, especially because cases occur mostly during the rainy season, and are scattered over a vast territory. communication and network coverage may be erratic, and security issues may also occur. this requires adequately staffed, welltrained study teams to be deployed over a number of peripheral health facilities, with logistical challenges and inherent high costs. this, plus the fact that drugs are registered for plague (based on the 'animal rule') and that national and international guidelines exist (based on empirical regimens), along with the general lack of funding options for plague, has essentially discouraged the conduct of treatment trials. where necessary, obtain the approval of the above parties for all substantial amendments to the original approved documents. written informed consent to participate will be obtained from all participants. author details recruitment start date: planned february 2020 planned recruitment end date additional file 1. : patient information sheet adverse event; c: celsius; caf-1 gene: chromatin assembly factor-1 ci: confidence interval; cioms: council of international organizations of medical sciences; clsi: clinical & laboratory standards institute; cpl: clinical plague laboratory; crf: case report form d: day; dfid: department for international development; dsmb: data and safety monitoring board; elisa: enzyme-linked immunosorbent assay f1: fraction 1 antigen; fda: food and administration; gcp: good clinical practice; gdpr: general data protection regulation igm: immunoglobulin m; inv1100 gene: chromosomal invasin gene ppi: per protocol infected; qpcr: quantitative polymerase chain reaction rct: randomized clinical trial; rdt: rapid diagnostic test; rr: respiratory rate sae: serious adverse event; sap: statistical analysis plan; toc: trial operations committee; who: world health organization plague around the world in 2019 epidemiological characteristics of an urban plague epidemic in madagascar report on the outbreak of bubonic plague: being a report based upon observations on 939 cases of bubonic plague treated at the municipal hospital for infectious diseases at arthur road treatment of plague with gentamicin or doxycycline in a randomized clinical trial in tanzania successful treatment of human plague with oral ciprofloxacin drugs@fda: fda approved drugs world health organization. plague around the world in 2019 effect of antibacterial therapy on the epidemic threat of experimental pneumonic plague in monkeys evaluation of the effectiveness of antibacterial substances in treating an experimental form of bubonic plague in monkeys world health organization. plague around the world publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to acknowledge the contribution of dr. feno rakotoarimanana and inès vigan-womas for their advice and contribution to this protocol. received: 16 april 2020 accepted: 29 july 2020 this protocol was written by po with assistance from jb and based on the main study protocol written by po, ag, te, mr, rr, as, lb, al and jb. clinical guidance was provided by po, rr, mr and as. all authors have approved the submitted manuscript. the authors declare that they have no competing interests. this trial is supported by the department for international development and wellcome [grant number 216273/z/19/z]. the role of the funder is to provide financial support for the trial. a representative of the funder will act as an observer on the trial steering committee. the trial collaborators are responsible for the design, management and analysis of the trial and the publication of the trial results. as sponsor of the trial, the university of oxford is the owner of the data. on the conclusion of the trial, oxford will provide a copy of the trial dataset to the trial investigators at institut pasteur de madagascar, centre hospitalier universitaire joseph raseta befelatanana and centre d'infectiologie charles mérieux (antananarivo) and the trial statistician at the london school of hygiene and tropical medicine in order for the trial team to fully participate in the development of the main publication. not applicable-no details, images or videos relating to an individual person have been collected as part of this publication. the investigators will ensure that this study is conducted in accordance with the current version of the declaration of helsinki (2013 version) and the applicable principles of the international committee on harmonization of good clinical practice (gcp-ich e6). the protocol, the informed consent form and the crf have received approval from the madagascar biomedical research ethics committee, and the protocol, patient information sheet and informed consent form have received approval from the oxford tropical research ethics committee and the ethics committee of the london school of hygiene and tropical medicine. the chief investigator will submit and, key: cord-034257-kl2ccmz5 authors: de jonge, jeroen c.; woodhouse, lisa j.; reinink, hendrik; van der worp, h. bart; bath, philip m. title: precious: prevention of complications to improve outcome in elderly patients with acute stroke—statistical analysis plan of a randomised, open, phase iii, clinical trial with blinded outcome assessment date: 2020-10-26 journal: trials doi: 10.1186/s13063-020-04717-0 sha: doc_id: 34257 cord_uid: kl2ccmz5 rationale: aspiration, infections, and fever are common in the first days after stroke, especially in older patients. the occurrence of these complications has been associated with an increased risk of death or dependency. aims and design: prevention of complications to improve outcome in elderly patients with acute stroke (precious) is an international, multi-centre, 3 × 2 factorial, randomised, controlled, open-label clinical trial with blinded outcome assessment, which will assess whether prevention of aspiration, infections, or fever with metoclopramide, ceftriaxone, paracetamol, respectively, or any combination of these in the first 4 days after stroke onset improves functional outcome at 90 days in elderly patients with acute stroke. discussion: this statistical analysis plan provides a technical description of the statistical methodology and unpopulated tables and figures. the paper is written prior to data lock and unblinding of treatment allocation. trial registration: isrctn registry isrctn82217627. registered on 22 september 2015. the trial was prospectively registered. in the first days after stroke, about half of all patients develop one or more complications, including aspiration, infections, or fever. the risk of developing these events is greater in patients of higher age or with more severe stroke [1] [2] [3] . these complications can impede functional recovery, prolong hospital admissions, and are independently associated with an increased risk of death or longterm dependency [1, 2, [4] [5] [6] [7] [8] [9] [10] [11] . the risk of developing these complications can be reduced by very simple, safe, and inexpensive measures, such as metoclopramide for the management of dysphagia, antibiotics for the prevention of infections, and paracetamol for the prevention of fever, but it is uncertain whether these measures also improve functional outcome [12] [13] [14] [15] . in some generally small, randomised trials, preventive treatment with these drugs not only convincingly reduced the risks of aspiration, infections, or fever by one third to one half, but was also associated with clear trends towards a lower risk of death or poor outcome [12] [13] [14] [15] . however, in two large randomised clinical trials, preventive treatment with antibiotics did not improve functional outcomes [16, 17] . guidelines of the european stroke organisation concluded that there is insufficient evidence from randomised trials to make strong recommendations on whether, when, and to whom preventive antibiotic or antipyretic treatment should be given after ischaemic stroke or intracerebral haemorrhage [18, 19] . the prevention of complications to improve outcome in elderly patients with acute stroke (precious) trial will assess whether prevention of aspiration, infections, or fever with metoclopramide, ceftriaxone, paracetamol, or any combination of these in the first 4 days after stroke onset improves functional outcome at 90 days in older patients with acute stroke. the current paper describes the statistical analysis plan (sap) of the trial and conforms to the guidelines set by gamble et al. [20] . the details of the study protocol of the precious trial have been published earlier [21] . precious has received funding from the european union's horizon 2020 research and innovation programme under grant agreement no. 634809. precious is an international, multi-centre, multifactorial, randomised, controlled, phase iii, open-label clinical trial with blinded outcome assessment (probe). the primary objective is to assess whether prevention of aspiration, infections, or fever with metoclopramide, ceftriaxone, paracetamol, or any combination of these in the first 4 days after stroke onset improves functional outcome at 90 days in older patients with acute stroke. patients will be randomly allocated in a 2 × 2 × 2 factorial design to any combination of open-label oral, rectal, or intravenous metoclopramide (10 mg thrice daily); intravenous ceftriaxone (2000 mg once daily); oral, rectal, or intravenous paracetamol (1000 mg four times daily); or usual care, started within 24 h after symptom onset and continued for 4 days or until complete recovery or discharge from hospital, if earlier. in patients with moderate to severe renal impairment or with severe hepatic impairment, the dose of metoclopramide is reduced to 5 mg thrice daily, and in patients with end-stage renal disease to 2.5 mg thrice daily. patients will be stratified according to country (estonia, germany, greece, hungary, italy, the netherlands, norway, poland, uk), and there will be 5 minimisation factors: age (66-75 years; > 75 years), sex (male vs. female), stroke type (ischaemic stroke vs. intracerebral haemorrhage), stroke severity (nihss 6-12 vs. > 12), and diabetes mellitus (yes vs. no).a total of 3800 patients will be recruited, based on the sample size calculation described in the previously published protocol [21] . an independent data and safety monitoring board (dsmb) will conduct unblinded interim analyses after 600, 1200, 1800, 2400, and 3000 patients have completed follow-up to assess the safety of the interventions in the trial. with respect to efficacy, the dsmb will conduct unblinded interim analyses after 2400 patients had their final follow-up. dsmb members will receive listings of all sae reports as well as unblinded aggregate summaries of data by treatment groups for review in closed meetings. the results of these interim analyses are confidential and limited to the members of dsmb. this statistical analysis plan (sap) will be signed off by the trial steering committee and then submitted for publication prior to data lock and final analysis. the final statistical analysis will be performed once recruitment has ceased, final follow-up and final outcome adjudication have been completed, final data have been checked and any errors corrected, and the database has been locked. the analyses will be carried out according to the current statistical analysis plan. the statistical analyses will be performed by the nottingham stroke trial unit (nstu) at the university of nottingham (unott) in collaboration with the umc utrecht. the study population will consist of patients aged 66 years or older who are hospitalised with moderately severe to severe (national institutes of health stroke scale (nihss) ≥ 6) acute ischaemic stroke or intracerebral haemorrhage. patients will only be included if treatment can be started within 24 h of stroke onset. for a complete overview of the inclusion and exclusion criteria, we refer to the study protocol [21] . patients are planned to be recruited in about 80 hospitals in 9 european countries over a period of about 4 years. to increase the generalisability of the findings, these countries are distributed across europe and include estonia, germany, greece, hungary, italy, the netherlands, norway, poland, and the uk. for the same reason, the trial will recruit patients both in academic and regional hospitals ( table 1 , fig. 1 ). the primary outcome measure is the score on the modified rankin scale (mrs) at 90 days (± 14 days). the mrs is an ordinal scale ranging from 0 to 6 [22] . the mrs assessment at 90 days will be during a hospital/home visit or by telephone, and the assessment or a report thereof will be recorded using a digital video camera. three blinded raters will view the videotape and adjudicate a score on the mrs. pre-stroke method of food intake oral softened food or fluids only paracetamol acute stroke treatment (%) data are n (%) or median [iqr] . mrs modified rankin scale, nihss national institutes of health stroke scale, bp blood pressure for each patient, a median mrs score will be calculated from the three mrs scores obtained through centralised adjudications by raters who are blinded to treatment allocation. the use of three scores increases the precision in scoring and statistical power as compared to a single mrs assessment [23] . the primary effect estimate will be the difference in the mrs scores between the active treatment group and controls assessed using ordinal logistic regression, and will be expressed as an odds ratio with 95% confidence interval [24] . the primary analysis will be performed on all randomised patients with a valid mrs score at 90 days. the distribution of the mrs scores will be shown as a figure (fig. 2 ). three separate primary analyses will be performed for each intervention vs. their respective controls (e.g. metoclopramide vs. nonthe primary analyses will be adjusted for stratification (country), minimisation (age, sex, stroke type, stroke severity, diabetes), and other baseline prognostic (e.g. premorbid mrs, atrial fibrillation, reperfusion treatment [alteplase and/or thrombectomy], time from onset to randomisation) factors, and treatment allocation for the other two strata of the trial (table 2) . comparison of the effect of the three intervention groups vs. their respective controls on the primary outcome will be performed in the following pre-specified subgroups (assuming sufficient numbers in each subgroup) with assessment of interaction between treatment and the minimisation factors (these subgroup analyses are considered hypothesis-generating) ( table 3) : age (≤ 75, > 75 years); sex (male, female); stroke type (ischaemic stroke, intracerebral haemorrhage); stroke severity (nihss 6-12, > 12); diabetes mellitus (yes, no). in addition, the interaction between treatment and other baseline factors will be assessed: presence of atrial fibrillation (yes, no); pre-stroke mrs score (0, > 0); reperfusion treatment (alteplase and/or mechanical thrombectomy); time to treatment (< 6, ≥ 6 h < 12 h, ≥ 12 h); treatment allocation for the other two trial strata (paracetamol-active, control; ceftriaxone-active, control; metoclopramide-active, control). since the study is not powered to detect interactions between the three interventions, these interactions will be investigated in secondary analyses. four sensitivity analyses of the mrs will also be performed: unadjusted ordinal logistic regression, adjusted analysis of mrs following regression imputation of missing data, multiple linear regression on the mean mrs score for each participant, and binary logistic regression on mrs > 2. the following secondary outcomes will be assessed at 7 days (± 1 day) or at discharge, if earlier: infections in the first 7 days (± 1 day; frequency, type, and clostridium difficile infections). infections will be categorised as diagnosed by the clinician and as judged by an independent adjudication committee (masked to treatment allocation); third generation cephalosporin resistance in the first 7 days (± 1 day), detected as part of routine clinical practice; antimicrobial use during the first 7 days, converted to units of defined daily doses according to the classification of the who anatomical therapeutic chemical classification system with defined daily doses index; serious adverse events (saes) in the first 7 days; in a subgroup of patients: presence of extended-spectrum beta-lactamase (esbl)-producing bacteria as detected by pcr in a rectal swab at day 7 (± 1 day, or at discharge, if earlier). the following secondary outcomes will be assessed at 90 days (± 14 days) ( table 4 ): death; unfavourable functional outcome, defined as mrs 3 to 6; disability assessed with the score on the barthel index (bi); cognition assessed with the montreal cognitive assessment (moca); quality of life assessed with the euroqol 5d-5l (eq-5d-5l) and eq-visual analogue scale (eq-vas); home time: the number of nights among the first 90 since stroke onset that are spent in the patient's own home or a relative's home. resource use will be censored at 90 days. where final follow-up occurs earlier, the last known placement will be extrapolated to 90 days; patient location over first 90 days (± 14 days): hospital, rehabilitation service, chronic nursing facility, and home. binary logistic regression will be used for binary outcomes (e.g. mrs > 2). cox proportional hazards regression will be used for time to events (e.g. death). ordinal logistic regression will be used for ordered categorical data (e.g. mrs). multiple linear regression will be used for continuous outcomes (e.g. bi, eq-vas). patients with missing outcome data will be excluded from the analysis. patients without a primary outcome assessment at 90 ± 14 days will be considered as a lost to follow-up. the total amount of patients who are lost to follow-up will be recorded and calculated for each treatment arm. the primary analysis will be performed on all randomised patients with a valid mrs score at 90 days. in a sensitivity analysis, missing mrs data will be imputed using multiple regression-based imputation. for the secondary outcome measures (barthel index, moca, eq-5d-5l, eq-vas), patients who die will be assigned a value one unit worse than any living value. this way, patients who die cannot be given a score similar to the worst score of patients who are alive, and it ensures that all patients will be included in the analysis. potential scores, with worst with dead added, are as follows: -modified rankin scale (mrs), 0 to 5 with death = 6; -barthel index (bi), 100 to 0 with death = − 5; -euroqol 5d-5l (eq-5d-5l), − 0.5 to 1 with death = 0; -euroqol visual analogue scale (eq-vas), 0 to 100 with death = − 1; -montreal cognitive assessment (moca), 0 to 30 with death = − 1. in the first 7 days after randomisation, all saes will be reported and described by duration (start and stop dates), severity, outcome, treatment, and relation to the investigational medical product (imp), or if unrelated, the cause. all saes will be tabulated per treatment stratum. in addition, any sae occurring between day 7 and the end of follow-up on day 90 (± 14 days) for which a causal relationship between the imp and the sae is considered at least a reasonable possibility (i.e. sars and susars) should be reported as other saes. the presence of any treatment restriction will be recorded at baseline and during the hospital phase, and classified as (1) do not resuscitate, (2) do not intubate and ventilate, (3) withhold other treatments that may prolong life, (4) withhold food, (5) withhold fluids, and (6) palliation (e.g. with morphine or a benzodiazepine). any combination of these strategies is possible. the primary study will report on the frequency of each treatment restriction, and further analyses on this topic will be published in future subgroup analyses. precious is an open-label clinical trial, and both patients and treating physicians are therefore aware of the assigned treatment. knowledge of treatment allocation can influence outcome assessment, and unblinded trials like precious are therefore at risk of detection bias. in addition, despite its apparent simplicity, assessment of the score on the mrs has been associated with considerable inter-observer variability, especially in multicentre studies, and may therefore affect trial power and treatment effect size. in precious, these two major issues are minimised through (1) online training and certification of outcome assessors via a link on the precious website and (2) central outcome assessment by three blinded adjudicators based on digital video recordings of the 90-day outcome interviews. this central adjudication by trained adjudicators offers several benefits [23] : 1. blinding is assured; 2. standardisation is possible across multiple regions and cultures; 3. statistical power is enhanced through the use of three repeated assessments; 4. the estimate of treatment effect size is restored (since statistical noise leads to underestimation); 5. it provides independent validation of the information that is collected, thereby minimising the risk of fraud; 6. site staff perform to a higher standard when aware that there will be review or audit of their activity. in addition, the risk of bias is reduced by performing the statistical analyses according to the intention-totreat principle and adjusting for the minimisation factors, other relevant baseline characteristics, and treatment allocation for the other two strata of the trial. analyses will be two-sided p < 0.05 with 95% confidence intervals presented. the trial is testing the effect of the interventions on mrs, and analyses in subgroups and on other outcomes are considered hypothesis-generating. hence, no adjustment will be made for multiplicity of testing. the data monitoring committee performs safety assessments using the haybittle-peto boundary rule (p < 0.001); hence, no significant spending of alpha will occur during the trial. all analyses will be two-tailed, and p values of < 0.05 will denote statistical significance; 95% confidence intervals will be provided. adjustment for multiple comparisons will not be performed, but all contrasts will be declared. compliance with allocated treatment will be tabulated. for each of the three study drugs, the number of received dosages will be calculated (maximum of four for ceftriaxone, twelve for metoclopramide, and sixteen for paracetamol). the number of patients who received the first dosage within the time window of 24 h will also be presented; if the dosage was not given within 24 h, the reason will be given (withdrawn informed consent, death, human error, other reason). all efficacy analyses will be performed on the intentionto-treat population. the robustness of the primary and key secondary analyses will be assessed in the perprotocol population. safety analyses will be performed on the safety population. the following population definitions will be used: ▪ intention-to-treat in primary efficacy analysis: all randomised participants who received any study medication and with a valid mrs score recorded at 90 days. ▪ intention-to-treat in primary safety analysis: all randomised participants with a vital status recorded at 90 days. ▪ per-protocol: all participants in the intention-to-treat population who are deemed to have no major protocol violations that could interfere with the objectives of the study. patients with protocol violations in trial eligibility will be included in the intention-to-treat population, but excluded in the per-protocol analysis. patients who withdrew informed consent before initiating treatment will be excluded from analysis. if (per accident) multiple randomisations are performed for a single patient, the result of the first randomisation will be used. the trial received approval from the central medical ethics committee of the university medical center utrecht, the netherlands, on 3 february 2016. the dutch national competent authority (centrale commissie mensgebonden onderzoek (ccmo)) declared to have no objection against the execution of the clinical trial within the netherlands on 17 november 2015. in addition, the national (and local, if applicable) medical ethical committees and competent authorities of the other 8 participating countries have approved the trial. the first patient was included in may 2016. the analysis and reporting of the trial will be in accordance with consort guidelines. after publication of the trial, to promote the independent re-use of precious data, a coded dataset will be made available in a public data repository within 18 months of the final follow-up of the last patient. coded data will also be included in the virtual international stroke trials archive (vista). supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04717-0. additional file 1: table s1 . protocol violations in eligibility. data are n (%). mrs, modified rankin scale. additional file 2: table s2 . compliance and cross-over in first 7 days. data are n (%). comparisons made by binary logistic regression. additional file 3: table s3 . secondary outcomes and treatment restrictions at 7 days. mrs, modified rankin scale. data are n (%) or median [iqr] . aor: adjusted odds ratio. comparison by adjusted ordinal logistic regression (aolr) or binary logistic regression (ablr). * converted to units of defined daily doses according to the classification of the who anatomical therapeutic chemical classification system with defined daily doses (ddd) index. additional file 4: table s4 . overview of safety. data are n (%). sae, severe adverse event; sar, severe adverse reaction; susar, severe unexpected serious adverse reaction. comparisons made by binary logistic regression. medical complications after stroke characteristic adverse events and their incidence among patients participating in acute ischemic stroke trials development and internal validation of a prediction rule for post-stroke infection and poststroke pneumonia in acute stroke patients post-stroke infection: a systematic review and meta-analysis therapeutic hypothermia in acute ischemic stroke impact of fever on outcome in patients with stroke and neurologic injury: a comprehensive meta-analysis effect of hyperthermia on prognosis after acute ischemic stroke dysphagia after stroke: incidence, diagnosis, and pulmonary complications temporal profile of body temperature in acute ischemic stroke: relation to infarct size and outcome poststroke dysphagia: a review and design considerations for future trials route of feeding as a proxy for dysphagia after stroke and the effect of transdermal glyceryl trinitrate: data from the efficacy of nitric oxide in stroke randomised controlled trial an early rise in body temperature is related to unfavorable outcome after stroke: data from the pais study antibiotic therapy for preventing infections in patients with acute stroke the paracetamol (acetaminophen) in stroke (pais) trial: a multicentre, randomised, placebo-controlled, phase iii trial safety and effect of metoclopramide to prevent pneumonia in patients with stroke fed via nasogastric tubes trial the preventive antibiotics in stroke study (pass): a pragmatic randomised open-label masked endpoint clinical trial prophylactic antibiotics after acute stroke for reducing pneumonia in patients with dysphagia (stroke-inf): a prospective, cluster-randomised, open-label, masked endpoint, controlled clinical trial european stroke organisation (eso) guidelines for the management of spontaneous intracerebral hemorrhage european stroke organisation (eso) guidelines for the management of temperature in patients with acute ischemic stroke guidelines for the content of statistical analysis plans in clinical trials precious: prevention of complications to improve outcome in elderly patients with acute stroke. rationale and design of a randomised, open, phase iii, clinical trial with blinded outcome assessment contemporary outcome measures in acute stroke research improving the efficiency of stroke trials statistical analysis of the primary outcome in acute stroke trials publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations none. hbvdw is the precious coordinating investigator. all authors contributed to the design of the statistical analysis. jdj wrote the first draft of the manuscript, and all authors reviewed the manuscript carefully. all authors read and approved the final version of the manuscript. the details of the study protocol have been published earlier [20] . after publication of the trial, to promote the independent re-use of precious data, a coded dataset will be made available in a public data repository within 18 months of the final follow-up of the last patient. coded data will also be included in vista. the primary ethics approval for the precious trial has been provided by the medical ethics committee of the university medical center utrecht, utrecht, the netherlands (nl54304.041.13). we have obtained informed consent from all participants in the study. key: cord-004339-7nwpic3d authors: rennie, katherine j.; o’hara, james; rousseau, nikki; stocken, deborah; howel, denise; ternent, laura; drinnan, mike; bray, alison; rooshenas, leila; hamilton, david w.; steel, alison; fouweather, tony; hynes, ann-marie; holstein, eva-maria; oluboyede, yemi; abouhajar, alaa; wilson, janet a.; carrie, sean title: nasal airway obstruction study (nairos): a phase iii, open-label, mixed-methods, multicentre randomised controlled trial of septoplasty versus medical management of a septal deviation with nasal obstruction date: 2020-02-13 journal: trials doi: 10.1186/s13063-020-4081-1 sha: doc_id: 4339 cord_uid: 7nwpic3d background: septoplasty (surgery to straighten a deviation in the nasal septum) is a frequently performed operation worldwide, with approximately 250,000 performed annually in the us and 22,000 in the uk. most septoplasties aim to improve diurnal and nocturnal nasal obstruction. the evidence base for septoplasty clinical effectiveness is hitherto very limited. aims: to establish, and inform guidance for, the best management strategy for individuals with nasal obstruction associated with a deviated septum. methods/design: a multicentre, mixed-methods, open label, randomised controlled trial of septoplasty versus medical management for adults with a deviated septum and a reduced nasal airway. eligible patients will have septal deflection visible at nasendoscopy and a nasal symptom score ≥ 30 on the nose questionnaire. surgical treatment comprises septoplasty with or without reduction of the inferior nasal turbinate on the anatomically wider side of the nose. medical management comprises a nasal saline spray followed by a fluorinated steroid spray daily for six months. the recruitment target is 378 patients, recruited from up to 17 sites across scotland, england and wales. randomisation will be on a 1:1 basis, stratified by gender and severity (nose score). participants will be followed up for 12 months post randomisation. the primary outcome measure is the total snot-22 score at 6 months. clinical and economic outcomes will be modelled against baseline severity (nose scale) to inform clinical decision-making. the study includes a recruitment enhancement process, and an economic evaluation. discussion: the nairos trial will evaluate the clinical effectiveness and cost-effectiveness of septoplasty versus medical management for adults with a deviated septum and symptoms of nasal blockage. identifying those individuals most likely to benefit from surgery should enable more efficient and effective clinical decision-making, and avoid unnecessary operations where there is low likelihood of patient benefit. trial registration: eudract: 2017–000893-12, isrctn: 16168569. registered on 24 march 2017. (continued from previous page) discussion: the nairos trial will evaluate the clinical effectiveness and cost-effectiveness of septoplasty versus medical management for adults with a deviated septum and symptoms of nasal blockage. identifying those individuals most likely to benefit from surgery should enable more efficient and effective clinical decision-making, and avoid unnecessary operations where there is low likelihood of patient benefit. keywords: nasal septum, nasal obstruction, septoplasty, turbinates, mometasone furoate, clinical trial, cost-effectiveness, process evaluation background septoplasty is surgery to straighten the nasal partition between the two nostrils (the septum). septoplasty is a commonly conducted operation worldwide, with approximately 250,000 operations performed annually in the us and approximately 22,000 in the united kingdom (uk) [1, 2] . most of these are carried out for nasal blockage and associated symptoms such as a snoring and sleep disturbance. nasal blockage is one of the commonest complaints presenting to otolaryngologists. however, the causes may be multiple, and several may be co-existent. septal deviation or lesions in the nasal passages, such as nasal polyps or enlarged adenoids or turbinates, may cause a 'fixed' sensation of blockage. 'fluctuating' blockage symptoms may be caused by inflammatory conditions of the nasal epithelium such as infective or allergic rhinitis. in addition, the 'nasal cycle', a spontaneous physiological congestion and decongestion of the nasal cavity, compounds the challenge in characterising and assessing nasal patency [3] . the impact of the 'nasal cycle' can be mitigated by measuring nasal airflow following therapeutic nasal decongestion [3] . ideally, the septum runs down the centre of the nose. if it is not straight, perhaps because of injury or a developmental anomaly, it may narrow one or both sides of the nose and obstruct airflow. a perfectly straight nasal septum in adults is rare and some degree of deviation is an accepted norm. however, in instances where there are symptoms of nasal obstruction and a concomitant deviation of the septum, patients may be offered the septoplasty operation. on the sidewalls of the nose are 'turbinates', tissue structures which are rich in blood vessels and glands. often when the septum narrows one side of the nose, it creates a larger space on the other side, into which the turbinate on that side expands. medical management using topical nasal steroid sprays decongests the nasal lining and may lead to improvement in the symptoms of nasal blockage. however, such treatments are required on a daily, ongoing basis and in practice may not be successful. in addition, side effects of nasal dryness, irritation and bleeding may impact on treatment satisfaction and compliance. when surgery to straighten the septum is carried out, some surgeons also reduce the contralateral turbinate tissue. potential complications of septoplasty include septal perforation, septal adhesions and bleeding [4] . post-operative pain is common although this is reduced if sutures rather than nasal packing are used [4] [5] [6] . patients typically are advised to take several days off work or usual activities after the operation. septoplasty has no defined selection criteria, particularly in patients whose principal symptoms are sleep related, and clinical practice varies in different centres. the mode of action of septoplasty in sleep-related breathing disorders is not fully understood [7] [8] [9] . the effectiveness of septoplasty with or without turbinate surgery remains unclear and there is a lack of high-quality evidence of its benefit in the literature [10, 11] . not all patients improve with surgery. estimates of persistent septal deviation following a septoplasty procedure range from less than 6% [12] to 20% [13] . where septoplasty fails and further surgery becomes necessary, revision rates are reported to be high [14] . there is also a lack of robust evidence about the additional benefit of turbinate surgery [11] . one study showed reduced revision rates for septoplasty when the turbinate tissue is reduced [15] ; other studies report no added long-term benefit from turbinate reduction [16] [17] [18] . currently, most septal surgery is based on subjective, unstandardised clinical impressions of the contribution of the nasal septum to patients' symptoms. there is also no good comparative evidence regarding alternatives to septal surgery; nor about who might most benefit, to inform patients' and doctors' shared surgical decisionmaking [11] . whilst it is recognised that that the evidence base for septoplasty is ambiguous [11] , it is important to take into account the variations between men and women in relation to the operation. firstly, septoplasty is more common in men [4, 11] and, secondly, there is a known gender influence on response to nasal-patient reported outcome measures [1] . the aim of nairos is to establish, and inform guidance for, the best management strategy for patients with nasal obstruction associated with a deviated nasal septum, via a randomised controlled trial (rct) of surgery versus medical management across 17 sites in both secondary and tertiary hospitals across england, scotland and wales. to establish, and inform guidance for, the best management strategy for participants with nasal obstruction associated with a deviated septum, via a randomised controlled trial comparing the clinical and costeffectiveness, of nasal septoplasty plus/minus (±) contralateral turbinate reduction versus medical management. the study objectives are split into three different aspects: clinical effectiveness, economic evaluations and mixedmethod process evaluation. clinical effectiveness to measure clinical effectiveness according to: subjective self-report rating of nasal airway obstruction heterogeneity of estimated treatment effect specifically according to severity of obstruction and gender objective measures of nasal patency number of adverse events (aes) and additional interventions required technical failure in the surgical arm how well those agreeing to enter the trial reflect those screened for eligibility the cost-effectiveness of each intervention the cost-utility with outcomes reported as incremental cost per quality adjusted life year (qaly) gained a longer-term economic model to assess costs and health consequences beyond 12-month follow-up period all economic analyses will be conducted from the perspective of the national health service (nhs) and participants mixed-methods process evaluation of the trial and interventions our mixed-method process evaluation will identify, describe, understand and address: barriers to optimal recruitment, and potential solutions to address these, through integration of the quintet recruitment intervention (qri) [19, 20] participants' and healthcare professionals' experiences of trial participation and the interventions under evaluation factors likely to influence wider implementation of trial findings the design, measured outcomes and analysis of the process evaluation and qri are detailed later in this manuscript. a multicentre, randomised controlled, open-label trial, incorporating a qualitative process and economic evaluation. participants will be randomised on a 1:1 basis between septoplasty, with or without turbinate reduction, versus medical management (isotonic saline nasal spray (sterimar) and mometasone nasal spray) of nasal obstruction. participants in the medical management arm will be asked to use the nasal sprays twice daily for 6 weeks, then once daily for the remainder of the 6-month period. recruitment will take place over 20 months, with trial completion complete at 42 months (submission of final report). the trial will take place in 17 nhs hospitals across scotland, england and wales (see the isrctn registry number 16168569). an overview of the nairos schedule of events patient pathway is shown in fig. 1 . adults (aged ≥ 18 years) referred by their general practitioner (gp) to ear, nose and throat (ent) secondary care outpatient clinics who are found to have a deviated septum on nasendoscopy and reduced nasal airway as indicated by a nose score ≥ 30. ent staff will also be recruited for participation in a process evaluation. the nairos eligibility criteria are listed in table 1 . hospital researchers will proactively identify nairoseligible patients through triage of referral letters of rhinology patients to the ent department, and issue an invitation to attend a research clinic. patients attending a research clinic will, where possible, have been sent the patient information sheet (pis) with their appointment details, and have been directed to the patient information video, available at www.nairos.co.uk. all patients will have been given a minimum of 24 h after receiving the pis to decide whether or not they would like to take part. the main pis can be found in additional file 1. consent a delegated member of the research team will undertake informed consent discussions with the opportunity for the patient to ask any questions and discuss the trial in more detail. patients will be invited to give informed, written consent in three stages. firstly, consent to undergo screening (eligibility). secondly, consent to have the discussion about the nairos trial with the investigator audio-recorded and their details passed onto • any prior septal surgery • systemic inflammatory disease or the use of any current oral steroid treatment within the past 2 weeks • granulomatosis with polyangiitis • nasendoscopic evidence of unrelated associated pathology, e.g. adenoid pad, septal perforation, chronic rhinosinusitis indicated by the presence of polyposis or pus • any history of intranasal recreational drug use within the past 6 months • breast-feeding, pregnancy or intended pregnancy for the duration of involvement in the trial • bleeding diathesis • therapeutic anticoagulation (warfarin/novel oral anti-coagulant (noac) therapy) • clinically significant contraindication to general anaesthesia • patients known to be immuno-compromised • those in whom an external bony deformity substantially contributes to the nasal obstruction a member of the qualitative team for a telephone interview. finally, eligible patients are invited to give consent for the main trial, and to also give consent to potential future sharing of their anonymised data with other researchers not related to the nairos study. the patient informed consent form can be found in additional file 2. screening screening data used to assess eligibility will include: clinical examination (including nasal endoscopy) nasal obstruction symptom evaluation scale (nose) scoreconfirmation of total ≥ 30 age baseline recording of four core features at endoscopy of the undecongested nose • the side of the maximum convexity • one main site of deflection on each sideanterior/ posterior/upper/lower/all) • confirmation that there is no excluding inflammatory processpus/polyps/adenoids • magnitude of observer-rated airway block (< 50%; ≥ 50%) if the participant is unable to complete the endoscopic examination without topical preparation, it can be performed after the airway assessment of the decongested nose. the nose scale is a validated five-item, unifactorial self-report of nasal-block severity which has been applied in previous research and audit studies [21, 22] . the three recognised nose-derived categories of baseline severity used will be: 30-50 = moderate, 55-75 = severe, 80-100 = extreme [22] . for nairos, it is anticipated that baseline severity will be the most important determinant of outcome. those with a nose score of less than 30 will be excluded from nairos on the basis of having symptoms that are too mild to warrant inclusion. randomisation at the baseline visit, consenting, eligible patients will be randomised on a 1:1 basis using random permuted blocks of variable length. stratification will be by gender and baseline severity (nose score). randomisation will be administered centrally by the newcastle clinical trials unit (nctu) web-based system. the treatment allocation is open label and the randomisation system will provide a unique trial identifier for each participant via email to a delegated member of site staff. participants will be randomised between: 1. septoplasty with or without unilateral turbinate reduction 2. medical management participants allocated to the septoplasty group will undergo surgical correction of the nasal septal deviation ± unilateral reduction of the inferior turbinate on the concave side. a preliminary secondary care feasibility exercise revealed that there is considerable variation in surgical practice around the uk; rates of contralateral turbinate reduction varied between nairos centres from 30 to 65% of septoplasties. as a pragmatic study, nairos does not ask surgeons to change their usual practice in relation to contralateral turbinate reduction. nairos surgeons may or may not carry out unilateral turbinate surgery on the wider side, according to their assessment of the individual patient airway. intention to reduce one turbinate will be recorded prior to randomisation. details of the actual surgery performed will also be collected. participants will have a closed septoplasty, will be sutured, not packed, and will be a day case (where possible). the recommended post-operative twice-daily regimen will be of saline douche plus naseptin nasal cream (or if the patient is allergic to the peanut content of naseptin, bactroban 2% ointment). participants will be recommended to take a few days off work. nasal-steroid and saline sprays should not be part of routine standard post-operative care for nairos. any additional medication required by participants will be recorded as concomitant medication. surgery must be carried out anytime up to 8 weeks (+ 4 weeks) after randomisation. the additional 4-week window is to allow for extenuating circumstances only, such as unexpected patient or clinical reasons that necessitate a delay in surgery. reasons for delays to surgery will be collected and reported. the surgical intervention will be performed by surgeons who have completed their training. patients randomised to the medical management arm will be asked to use a combination of an isotonic spray with a full twice-daily dose of a fluorinated steroid spray (mometasone furoate) which is a typical maximal medical therapy regime over a 6-month period. preparatory work by the chief investigator indicated that most patients referred from their gp have never used this sustained combination therapy. sterimar isotonic nasal spray dose: one spray (metred dose) into each nostril prior to using the mometasone nasal spray. mometasone nasal spray dose: 100 mcg (two sprays) into each nostril twice daily for 6 weeks, followed by 100 mcg (two sprays) into each nostril once daily or 50 mcg (one spray) into each nostril twice daily for the remainder of the 6-month period. participants who wish to discontinue their allocated treatment, but remain in the trial, may access other treatments via the standard local nhs route. such participants will be followed up as per their allocated treatment intervention arm. participants in the surgical arm who wish to pursue medical treatment will not receive the trial investigational medicinal product (imp) prescription. participants in the medical arm who wish to receive surgery and remain eligible for septoplasty should be added to the elective nhs waiting list. the primary analysis is comparison of the comprehensive, validated sino nasal outcome test-22 (snot-22) [23] patient-reported scores at 6 months from randomisation (− 2 weeks to + 4 weeks), with complete follow-up of participants to 12 months post randomisation. snot-22 is a commonly employed patient reported outcome measure in the assessment of patients with pathologies of the nose and sinuses [23] [24] [25] [26] [27] [28] [29] [30] and was first applied to septoplasty in 2003 [31] . our ppi work found that patient symptoms mapped better to the snot-22 than to the nose and that patients preferred the snot-22 measure. to maximise collection of primary outcome measure, participants who cannot attend the 6-month follow-up visit may complete snot-22 by post. secondary outcome measures can be categorised into patient-reported, safety, economic, exploratory and qualitative. patient reported outcome measures (proms) proms will be used to measure long-term change in nasal patency and quality of life: snot-22 subscales (rhinologic, sleep, ear/facial pain, psychological) at 12 months nose scale at 12 months double ordinal airway subjective scale (doass)administered post nasal decongestant use only at 12 months. doass is a subjective comparator of right and left nasal patency [32] allowing direct comparison with the spirometry measures safety outcomes safety outcomes will be measured by the number and characteristics of any aes, and surgical complication/failure and re-intervention within 12 months. economic outcomes economic outcome measures include: qaly gained using the 36-item short form health survey (sf-36) questionnaire (1-week recall), further converted into qalys using the health economy survey derived from sf-36 (sf-6d) algorithm [33] , at 12 months, and aes avoided use of and timing of additional interventions in primary and secondary care recorded by health care utilisation questionnaire at 6 months and 12 months number of days unable to undertake usual activities recorded by health care utilisation questionnaire at 6 months and at 12 months incremental cost per change in snot-22 at 12 months costs to nhs and participants at 12 months longer-term economic model to assess costs and health consequences beyond the trial exploratory outcome measures two of the most common objective measures of nasal patency, used in some overseas healthcare systems to assess likely benefit from septoplasty, are peak nasal inspiratory flow rate (pnif) and nasal partitioning ratio (npr) [34] . pnif and npr will be used in this trial as exploratory outcome measures. all sites will be provided with two devices to measure two different measurements of nasal patency: pnif, measured with a pnif meter (peak nasal inspiratory flow (pnif) meter; gm instruments, kilwinning, uk) npr, measured using the nv1 rhinospirometer (nv1 rhinospirometer; gm instruments, kilwinning, uk) the two standard measurements will each be made before and after decongesting the nasal turbinate tissue with xylometazoline at baseline and at 6 and 12 months following randomisation. pnif measures the peak flow rate of air through both nostrils during inhalation using a pnif meter with a face mask. the participant holds the mask over the nose and mouth, closes the mouth and inhales maximally (sniffs). pnif has been shown to respond to septoplasty/turbinectomy [35] and can, therefore, be used for an overall assessment of nasal airflow impairment, and as an objective outcome measure from surgery. however, pnif does not differentiate between the two nostrils. bench testing shows the nv1 rhinospirometer to be an accurate and precise objective marker of airflow symmetry [36] . the nv1 rhinospirometer has two separate channels to measure the volume of air passing through each nostril, hence deriving the npr, the difference between right and left volumes divided by the sum. npr ranges from symmetrical (0) to completely unilateral (± 1). the npr appears to predict the septal surgery outcome [34, 37] . comparison of npr during both maximal inhalation and normal tidal breathing will allow the comparative utility of these two measures to be compared and demonstrate any change in nasal function following treatment. qualitative outcomes qualitative outcomes will be identified through observations of training and nairos meetings, interviews with health professionals and participants, and audio-recording of recruitment discussions. the trial schedule of events is presented as a flow diagram (fig. 1 ) and using the standard protocol items: recommendations for interventional trials (spirit) figure [ 38] (fig. 2) . participants recruited to the main trial will be followed up for 12 months from the point of randomisation. data including the number of participants screened, approached and interested in taking part will be collected via a log completed by site staff conducting screening. assessments pre-randomisation eligible patients who consent to participate in the main trial will have the following outcome measures administered prior to randomisation: site nursing staff will record details of any concomitant medication and aes during a phone call at 2 weeks after surgery has taken place, and at all scheduled trial visits. medical management arm data as a pragmatic trial using standard treatment as part of the medical management arm, precise assessment of any mometasone furoate spray and sterimar spray residuum will not take place. participant compliance with the imp does not form part of the trial monitoring plan. participants will be asked at the 6-month follow-up visit (visit 2) to estimate how many bottles of the sterimar and mometasone furoate spray they used. site nursing staff will record details of concomitant medication and any aes during a phone call at 2 weeks post randomisation and at all scheduled trial visits. data will be handled, computerised, stored and archived in accordance with the general data protection regulation (2018), and the latest directive on good clinical practice (gcp) (2005/28/ec). patient-identifiable data will remain at each site and not be collected as part of the trial dataset. patient identification on data collection tools used during screening will be through a unique sequential screening number allocated by site staff. patients recruited to the main trial will additionally be identified by a unique trial identifier number generated by the randomisation system. data will be transcribed and npr files uploaded by site staff to the trial's secure, password-limited, validated macro™ database (elsevier). the participant trial record, including completed paper data collection tools, will be archived at site for 5 years following the end of the trial. audio-recordings will be archived for 10 years. the trial will be conducted in accordance with the medicines for human use (clinical trials) regulations 2004 and subsequent amendments. all parties must abide by these regulations and the international conference on harmonisation-good clinical practice (ich-gcp) guidelines. participants who withdraw their consent from the trial, or are withdrawn by the investigator, will not be replaced. all data collected up until the point of withdrawal will be retained for nairos research purposes, and consent will be sought for this (additional file 2). the snot-22 minimal clinically important difference (mcid) in the national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis was 8.9 [23] . septal surgery is reported variously as showing reductions in total snot-22 scores above (10 points) [29] or below (4 points) this boundary [25] . in the absence of a specific figure for septoplasty mcid, nairos has assumed a clinically relevant reduction being at least 9 points. reported standard deviations (sd) of the snot-22 score were 18 [27] (in external septoplasty) to 24 [28] in septorhinoplasty, nairos assumed the larger, more conservative sd. sample size calculations were based on a t test for superiority assuming equal variance across groups, a conservative estimate given the primary analysis is based on adjustment for stratification covariates, increasing power. the target recruitment of 378 participants allows for 20% drop-outbased upon experience from our unit's two prior septal surgery audits [10, 39] . the remaining 302 participants (151 per arm at completion), are required to show a 9-point [23] difference in overall snot-22 score between arms, with 90% power and 5% type i error, assuming a sd of 24. primary outcome the primary analysis is comparison of snot-22 scores at 6 months by randomised treatment arm (immediate surgery vs medical management). mean overall scores will be presented by treatment group. the associated significance of any observed difference will be calculated in multivariable regression models adjusting any treatment effect by stratification factors, gender and nose severity at baseline. secondary analysis of the primary outcome measure will adjust for the influence of baseline severity snot-22 score as a continuous covariate, planned turbinate reduction as a binary covariate and other important demographic and clinical covariates at randomisation (including, but not exclusively, age, body mass index (bmi), smoking, endoscopic features). non-linear relationships between continuous baseline measures and outcome will be addressed by simple, and possibly more complex, fractional polynomial transformations. the nairos model will generate a linear predictor score of patient outcome weighted according to the statistical importance of each covariate. each patient's linear predictor score will be compared against observed score for internal validation. this model will be used to explore recommendations for treatment options. the importance of baseline severity, as a continuous distribution of nose score at randomisation, may be further explored graphically by subpopulation treatment effect pattern plots (stepp analysis) [40] to display the predicted point estimates of any treatment effect (with 95% ci) over the range of nose values (range 30-100 in nairos participants), further informing any patient selection guidance and recommendations. primary statistical analyses will be carried out on an intention-to-treat basis. the number of ineligible participants and reasons for ineligibility will be reported. a sensitivity analysis may be conducted and reported if the number of ineligible participants or participants not receiving the allocated treatment is excessive. participants may choose to discontinue the treatment to which they have been allocated, and may also ask that they receive an alternative treatment as per local standard nhs care. the implication of such treatment adjustments, which typifies surgical trials, is that the intention-to-treat analysis will produce a conservative estimate of the effect of septoplasty. non-compliance (including receiving the alternative treatment) may be addressed using an 'as treated' approach or complier average causal effect (cace) approach, since the intention-to-treat analysis under noncompliance is biased when the intervention effect is large [41] . statistical methods for withdrawal of participants, based on statistical censoring, may be considered. tests of heterogeneity will assess robustness of the overall treatment effect across stratification subgroups, and by intention to perform unilateral turbinate reduction. there are no formal interim analyses of the primary outcome measure and there are no formal statistical stopping rules. decisions regarding continuation of the trial will be made at dmc meetings held every 6 months. decisions will be made on the basis of information presented in a statistical report that includes analysis of formal data snapshots, including safety data. analysis of secondary outcomes analyses of secondary outcomes will follow a broadly similar strategy. these will include the data at 6-month follow-up from the other outcomes (snot-22 subscales, nose, doass, sf-36) and that for all outcomes at 12-month follow-up. subjective scales, tabulated by arm and overall at randomisation, 6-month and 12-month follow-ups, will be compared by both summary statistics and graphical representation. multiple regression will be used to investigate longitudinal outcome scores between treatment groups at follow-up time points. variation between participants will be included as a random effect with an assumed normal distribution. analysis will include the stratification factors of baseline severity and gender. further adjusted analyses will include terms for baseline values of the scores and key demographic and clinical covariates. adverse events will be tabulated according to world health organisation (who) common terminology criteria for adverse events (ctcae) grade version 4.03. number of severe (ctc grade 3, 4 or 5) will be reported as a proportion of all aes. number of participants experiencing at least one severe ctcae will be reported as a proportion of all participants. surgical complication/failure and re-intervention will be tabulated and will not subject to statistical testing. technical failures from operations where widening of nasal airway was achieved yet the symptoms persist will be reported. analysis of exploratory outcomes three measurements each of pnif and npr during maximal inhalation will be made. either the maximum (pnif) or average (npr) value is used. summary statistics will be presented for pnif and npr by arm and overall, at baseline, 6-month and 12month follow-ups. design the process evaluation incorporates the qri and mixed qualitative methods. data collection and analysis will commence during study set-up and continue throughout the trial. randomising patients between surgical and medical arms can be challenging. the qri, based at bristol university, will assist in the identification and methods of addressing such challenges. the qri uses novel qualitative and mixed-method approaches pioneered during the national institute for health research (nihr) health technology assessment (hta)-funded protect (prostate testing for cancer and treatment) study [42] . these methods have since been applied to several other 'challenging' or controversial rcts in different clinical contexts, all of which have led to insights about recruitment issues and the development of generic and bespoke strategies to optimise recruitment [43] . the qri will coincide with the study set-up and the first year of recruitment, using qualitative and novel methods to investigate and address recruitment barriers (objective a, below) [43] [44] [45] . qualitative interviews will be conducted throughout the trial to investigate patients' and clinicians' experiences of the study procedures, interventions and barriers to implementing findings into practice (objectives b and c, below). sampling strategy the sampling strategy is informed by current and prior experience [42, 46, 47] . in keeping with the principles of rigorous qualitative research, sampling will be responsive to the study context. in some cases fewer interviews or observations will be conducted, and in others, additional data will be required to accommodate our emerging analysis or study events. numbers of interviews will be guided by 'data saturation'continued sampling until findings become repetitious. objective a: optimising recruitment -qri (study set-up and first year of recruitment) working in close collaboration with the trial management group (tmg), the qri team will assimilate investigational and interventional approaches to understand and address recruitment difficulties in the early stages of nairos. the findings and implications of the qri will continue to be implemented by the tmg and study investigators throughout the remainder of the trial recruitment period. the qri will proceed in two iterative phases: a detailed understanding of the recruitment process will be developed in phase i, leading to tailored interventions to improve recruitment in phase ii. phase i: understanding the recruitment process and how it operates in individual centres. a multi-faceted, flexible approach will be adopted, comprising one or more of the following methods: (a) in-depth interviews, conducted with: members of the tmg (n = 5-10); clinicians or researchers involved in trial recruitment (n = 10-12); and eligible patients who have been approached to participate in the trial (n = 5-10). interviews will explore views on trial processes, perceptions of equipoise, and information about how the protocol is operationalised in clinical centres (b) audio-recording and non-participant observation of consultations during which the trial is discussed with patients, enabling identification of clear and subtle obstacles to recruitment (c) mapping of eligibility and recruitment pathwaysnoting the point at which patients receive information about the trial, which members of the clinical team they meet, and the timing and frequency of appointments. the qri researcher will work closely with the clinical trials unit to compose logs of potential rct participants as they proceed through screening and eligibility phases (d) regular observation of tmg and investigator meetings to gain an overview of trial conduct and overarching challenges (logistical issues, etc.) (e) scrutiny of study documentation (e.g. piss) to identify aspects that are unclear or potentially open to misinterpretation phase 2: development and implementation of recruitment strategies. anonymised findings from phase i will be presented to the tmg, summarising the factors that appear to be hindering recruitment. a plan of action will be devised in collaboration with the tmg if there is consensus that aspects of practice are amenable to change. interventions will be tailored to the nature of recruitment challenges identified. generic forms of intervention may include 'tips' documents on how to explain trial design and processes. supportive feedback will be a core component of the plan of action, with the exact nature and timing of feedback dependent on the issues that arise. centre-specific feedback may cover institutional barriers, whilst multicentre group feedback sessions may address widespread challenges. individual confidential feedback will be offered where there is a need to discuss specific challenges or potentially sensitive issues. objectives b and c: understanding experiences of septoplasty and non-surgical management we will investigate patients' (n = [16] [17] [18] [19] [20] and health professionals' (n = 16-20) experiences of the interventions and trial participation through qualitative interviews conducted during patient follow-up. where possible, patients for the follow-up interviews will include those interviewed during the recruitment phase; additional participants will be recruited based on purposive and emergent criteria (e.g. patients who have declined their allocated treatment). we will identify any aspects of the care pathway which are problematic for patients or health professionals; and potential barriers and facilitators to wider acceptance and implementation of trial findings. a focus group of gps will explore preliminary trial findings and discuss implications for primary care management of nasal obstruction. our analysis of the implementation of study findings will be informed by normalisation process theory (npt) [48] . qualitative data management and analysis all interviews will be audio-recorded, transcribed verbatim and edited to ensure anonymity of respondents. contemporaneous field notes from non-participant observation in clinical settings will be edited to ensure anonymity of participants. data will be managed using nvivo software. the analysis will be conducted according to the standard procedures of rigorous qualitative analysis which we have described previously [49] , including open and focussed coding, constant comparison [50] , memoing [50] , deviant case analysis [51] and mapping [52] . we will undertake independent coding and crosschecking and a proportion of data will be analysed collectively in 'data clinics' where the research team share and exchange interpretations of key issues emerging from the data. audio-recorded recruitment consultations will be subjected to content, thematic and novel analytical approaches, including targeted conversation analysis [52] and quanti-qual appointment timing (the 'q-qat method') [53] . there will be a focus on aspects of information provision that is unclear, disrupted, or potentially detrimental to recruitment and informed consent. all participants who complete the nairos trial, or who discontinue the treatment interventions at any point, will be offered standard, local nhs care in discussion with their local investigator. the sponsor will provide indemnity in the event that trial participants suffer negligent harm due to the management of the trial. this indemnity will be provided under the nhs indemnity arrangements for clinical negligence claims in the nhs. the trial steering committee (tsc), data monitoring committee (dmc), trial statistician, data manager and other members of the central trial team as required will have access to the full trial dataset. individual site trial datasets will not be available to individual site investigators prior to publication of the main trial results. all requests for data should be directed to the corresponding author for consideration. access to the anonymised final trial dataset may be available following review; we will retain exclusive use until publication of major outputs. the results of the trial will be presented at topic-specific national or international conferences and published in a general medical journal with the monograph published by hta. authorship of all publications will be on a named individual authorship basis. for each publication, all individuals who fulfil the authorship definition for the publishing journal or site will be included as individually named authors. authorship order will be decided by the chief investigator and tmg. a lay summary of results and the hta report will be available on the nairos website. members of the patient and public involvement (ppi) panel will review results and they will be involved in writing lay summaries of results for dissemination to relevant patient groups. nctu staff will monitor trial conduct and data integrity to ensure that the trial is conducted in accordance to the latest directive on gcp (2005/28/ec). this will be detailed in a data management plan and a monitoring plan approved by the trial sponsor. safety reporting delegated nursing staff will interview participants to collect and record any aes. this will take place at every trial visit (n = 3), and also via safety phone calls; 2 weeks after randomisation for medical management arm participants, and 2 weeks after septoplasty for surgical arm participants. serious adverse events (saes) will be assessed for any relationship to the treatment intervention (causality), and expectedness (by reference to the reference safety information (rsi)) of any serious adverse reactions (sars). only a qualified medical doctor, delegated to do so at site, may assess the causality and expectedness of each sae. trial management group a trial management group, facilitated by nctu, will convene approximately monthly throughout the duration of the trial. members will consist of key nctu staff, the chief investigator, local clinical co-applicants, trial statisticians, a sponsor representative and staff representing health economics, qualitative and quintet recruitment intervention teams. independent data monitoring committee an independent data monitoring committee (dmc) has been appointed to provide an independent review of participant safety and data endpoints. the independent members comprise two statisticians and a clinician. the dmc will meet at least annually, and report directly to the trial steering committee (tsc). trial steering committee a tsc has been appointed to provide overall independent supervision of the trial. members consist of an independent chair, two independent clinicians, an independent statistician, an independent health economist and three patient representatives. the tsc will meet least annually, after a dmc meeting. all substantial changes to the protocol were approved by the local uk hra research ethics committee, and standalone minor changes (version 4.1) were approved by the health research authority (hra), prior to implementation at sites. the current, full protocol is available to view on the trial funder's website: https://fundingawards.nihr.ac.uk/search. a summary of key changes to the protocol during the trial is listed in table 2 . there is a paucity of evidence underlying the indications for septoplasty in the uk. at present, the decision to perform septoplasty is based on the clinician's subjective estimation of the impact on the affected nasal airway caused by a deviated septum. in addition, there is a lack of evidence of the impact of a standardised topical medical treatment regimen on the nasal airway in the presence of a septal deflection. at a time of rising healthcare costs and increasing scrutiny on the requirement to justify clinical interventions there is an urgent need to answer these questions. the aim of nairos is to perform a rct to compare surgical treatment to a standardised dual medical therapy (sterimar spray and mometasone spray) and estimate the effectiveness based on subjective nasal symptoms, objective airway measurements and the impact on quality of life. furthermore, a number of other interactions will be measured at baseline, 6 and 12 months following randomisation. the impact of known covariates including sex, turbinate enlargement and subjective degree of nasal obstruction will be assessed. nairos is a pragmatic 'real-world' trial, researching a common surgical intervention against a contemporary comparator in such a way that the results will be generalisable to nhs patients in whom it is offered. however, limitations are anticipated in both treatment arms. in the surgical arm clinicians may vary in their assessment and documentation of the nasal septum deflection. it is also recognised that there are shortcomings in objective measurements of the nasal airway [54] . in the medical arm we are not monitoring quantities of nasal-steroid used and instead relying on patientreported use. nairos will also compare the cost-effectiveness, to the patient and the nhs, of both the medical and surgical arms of the trial. the challenges and barriers to patient recruitment will be analysed by the quintet recruitment intervention with a view to identifying and minimising these. a qualitative evaluation will explore the views of participants and staff and their experience of the intervention to enable us to shape guidelines and inform clinical decision-making in patients with a deviated nasal septum. the overarching aim will be to shape future guidance on the management of a deviated nasal septum in an nhs setting. the nairos trial is currently working to protocol version 5.0, dated 16 january 2019. recruitment began on 18 january 2018, and is due to end on 31 january 2020. supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-4081-1. • specification of the location of the rsi within the mometasone smpc 3.0, 20 nov 2017 • specification of the decongestant spray to be used alongside the nasal patency measurements (xylometazoline) and classification of the decongestant spray as a nimp • clarification of the exclusion criteria regarding the use of orally administered steroids and updating the exclusion criteria to exclude patients who have an external bony deformity that is likely to make a substantial contribution to the nasal obstruction 4.0, 11 jun 2018 • update to the mometasone rsi • update the exclusion criteria from any history of intranasally administered recreational drug use to any history of intranasal recreational drug use within the past 6 months • clarify the clinical examination procedure to state that patients who request local anaesthetic for nasal endoscopy may have the nasal endoscopy assessment carried out after the other trial assessments have been completed • clarification of the timing for the surgical intervention to state that patients randomised to septoplasty must have their septoplasty anytime within 8 weeks of randomisation 4.1, 21 dec 2018 addition of a 4-week window to the timeline for surgery for use in extenuating circumstances (i.e. 8 weeks + 4 weeks) • change the window for the 6-month visit from ± 2 weeks to − 2 weeks/+ 4 weeks to maximise collection of the primary outcome measure • clarification of management of patients between the 6-month and 12-month follow-up visits • clarification of management and options for participants who wish to discontinue with their allocated treatment and explore other surgical or medical treatments as part of standard nhs care • state that discontinuation of allocated treatment does not constitute withdrawal from the trial. update to the rsi for the surgical intervention ambulatory sinus and nasal surgery in the united states: demographics and perioperative outcomes admitted patient care -england nasal patency: problems in obtaining standard reference values for the surgeon complications in septoplasty based on a large group of 5639 patients is nasal packing necessary after septoplasty? a meta-analysis open versus endoscopic septoplasty techniques: a systematic review and metaanalysis quality of life and symptoms before and after nasal septoplasty compared with healthy individuals surgical treatments for snoring nasal obstruction considerations in sleep apnea nasal septoplasty with submucosal diathermy to inferior turbinates improves symptoms at 3 months postoperatively in a study of one hundred and one patients septoplasty for nasal obstruction due to a deviated nasal septum in adults: a systematic review suturing of the nasal septum after septoplasty, is it an effective alternative to nasal packing? clinical outcomes of nasal septal surgery at high altitude revision septoplasty: a prospective disease-specific outcome study septoplasty with concomitant inferior turbinate reduction reduces the need for revision procedure outcomes of septoplasty a randomised clinical trial of turbinectomy for compensatory turbinate hypertrophy in patients with anterior septal deviations a randomized clinical study: outcome of submucous resection of compensatory inferior turbinate during septoplasty quality improvement report: improving design and conduct of randomised trials by embedding them in qualitative research: protect (prostate testing for cancer and treatment) study. commentary: presenting unbiased information to patients can be difficult optimising recruitment and informed consent in randomised controlled trials: the development and implementation of the quintet recruitment intervention (qri) outcomes after nasal septoplasty: results from the nasal obstruction septoplasty effectiveness (nose) study. otolaryngol head neck surg development of a severity classification system for subjective nasal obstruction psychometric validity of the 22-item sinonasal outcome test the sino-nasal outcome test (snot): can we make it more clinically meaningful? otolaryngol head neck surg does septoplasty enhance the quality of life in patients? prevalence of sinonasal outcome test (snot-22) symptoms in patients undergoing surgery for chronic rhinosinusitis in the england and wales national prospective audit functional and cosmetic outcomes of external approach septoplasty is the sino-nasal outcome test-22 a suitable evaluation for septorhinoplasty? evaluation of benefits of nasal septal surgery on nasal symptoms and general health gender-specific differences in chronic rhinosinusitis patients electing endoscopic sinus surgery can the sino-nasal outcome test (snot-22) be used as a reliable outcome measure for successful septal surgery? assessment of subjective scales for selection of patients for nasal septal surgery the estimation of a preference-based measure of health from the sf-36 the use of nasal spirometry as an objective measure of nasal septal deviation and the effectiveness of septal surgery use of peak nasal inspiratory flowmetry and nasal decongestant to evaluate outcome of septoplasty with radiofrequency coblation of the inferior turbinate the accuracy and reproducibility of rhinospirometry in detecting flow asymmetry in a nasal cavity model the value of bilateral simultaneous nasal spirometry in the assessment of patients undergoing septoplasty spirit 2013 explanation and elaboration: guidance for protocols of clinical trials nasal septal surgery: evaluation of symptomatic and general health outcomes patterns of treatment effects in subsets of patients in clinical trials reporting attrition in randomised controlled trials practice based, longitudinal, qualitative interview study of computerised evidence based guidelines in primary care the national randomised controlled trial of tonsillectomy in adults (nattina): a clinical and cost-effectiveness study: study protocol for a randomised control trial distributed decision making: the anatomy of decisions-in-action clear obstacles and hidden challenges: understanding recruiter perspectives in six pragmatic randomised controlled trials capturing users' experiences of participating in cancer trials evaluating complex interventions and health technologies using normalization process theory: development of a simplified approach and web-enabled toolkit a feasibility study incorporating a pilot randomised controlled trial of oral feeding plus pre-treatment gastrostomy tube versus oral feeding plus as-needed nasogastric tube feeding in patients undergoing chemoradiation for head and neck cancer (tube trial): study protocol the constant comparative method of qualitative analysis the quality of qualitative research. london: sage constructing grounded theory: a practical guide through qualitative analysis it's not just what you say, it's also how you say it: opening the 'black box' of informed consent appointments in randomised controlled trials a simple technique to identify key recruitment issues in randomised controlled trials: q-qat-quanti-qualitative appointment timing outcomes of septal surgery a systematic review of training programmes for recruiters to randomised controlled trials springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to thank the nairos site principal investigators for their continuing input into the nairos trial. nairos authors' contributions sc is the trial chief investigator and senior author. sc, jo'h and jaw led the funding application and protocol development. ds was the trial senior statistician during the funding bid and advised on trial design. dh is the trial senior statistician and advised on trial design, and leads on the statistical analysis plan. tf is the trial statistician. lt is the senior health economist, yo is the health economist, nr is the senior qualitative researcher and lr leads the quintet recruitment intervention. dwh contributed to the ppi for the funding bid. as, kjr, a-mh, e-mh and aa provided trial and database management and trial monitoring. md and ab developed the pnif and npr measurement protocols. kjr drafted the manuscript for this publication. all authors contributed to protocol development. all authors have revised the manuscript and given approval for the final version. this trial is funded by a national institute for health research health technology assessment programme grant (funder reference 14/226/07). the funder did not contribute to this manuscript, but provided review and approval prior to submission for publication. data-sharing is not applicable to this article as no datasets were generated or analysed for this article. the main pis and main informed consent form are presented as additional files 1 and 2, respectively.ethics approval and consent to participate conduct of the trial will be in accordance with the recommendations for physicians involved in research on human subjects adopted by the 18th world medical assembly, helsinki 1964 and later revisions. informed, written consent will be given by all participants prior to any trial screening procedures and participation in the trial.a favourable ethical opinion has been granted from the uk health research authority research ethics committee (north east -newcastle and north tyneside 2; study reference approval number 17/ne/0239). as per the uk hra process, this central rec review is applicable to all trial sites; local ethical review is not required. we will not commence recruitment at sites until local research and development confirmation of capacity and capability is received. the trial has also received approval from the uk medicines and healthcare products regulatory agency (mhra; study reference number 2017-000893-12). the trial has been included in the national institute for health research clinical research network (nihr crn) portfolio (nihr clrn study id: 35368). the trial sponsor is the newcastle upon tyne hospitals nhs foundation trust, freeman hospital, freeman road, high heaton, newcastle upon tyne, ne7 7dn. the trial sponsor has delegated responsibility for trial management to nctu, including trial design; review and approval of all localised patient-facing documentation prior to implementation at each site; collection, analysis and interpretation of data; writing of the protocol publication and final clinical report manuscripts. the sponsor did not contribute to this manuscript, but provided review and approval prior to submission for publication. not applicable. the authors declare that they have no competing interests.author details key: cord-033772-uzgya4k9 authors: strömmer, sofia; barrett, millie; woods-townsend, kathryn; baird, janis; farrell, david; lord, joanne; morrison, leanne; shaw, sarah; vogel, christina; lawrence, wendy; lovelock, donna; bagust, lisa; varkonyi-sepp, judit; coakley, patsy; campbell, lyall; anderson, ross; horsfall, tina; kalita, neelam; onyimadu, olu; clarke, john; cooper, cyrus; chase, debbie; lambrick, danielle; little, paul; hanson, mark; godfrey, keith; inskip, hazel; barker, mary title: engaging adolescents in changing behaviour (each-b): a study protocol for a cluster randomised controlled trial to improve dietary quality and physical activity date: 2020-10-15 journal: trials doi: 10.1186/s13063-020-04761-w sha: doc_id: 33772 cord_uid: uzgya4k9 background: poor diet and lack of physical activity are strongly linked to non-communicable disease risk, but modifying them is challenging. there is increasing recognition that adolescence is an important time to intervene; habits formed during this period tend to last, and physical and psychological changes during adolescence make it an important time to help individuals form healthier habits. improving adolescents’ health behaviours is important not only for their own health now and in adulthood, but also for the health of any future children. building on lifelab—an existing, purpose-built educational facility at the university of southampton—we have developed a multi-component intervention for secondary school students called engaging adolescents in changing behaviour (each-b) that aims to motivate and support adolescents to eat better and be more physically active. methods: a cluster randomised controlled trial is being conducted to evaluate the effectiveness of the each-b intervention. the primary outcomes of the intervention are self-reported dietary quality and objectively measured physical activity (pa) levels, both assessed at baseline and at 12-month follow-up. the each-b intervention consists of three linked elements: professional development for teachers including training in communication skills to support health behaviour change; the lifelab educational module comprising in-school teaching of nine science lessons linked to the english national curriculum and a practical day visit to the lifelab facility; and a personalised digital intervention that involves social support and game features that promote eating better and being more active. both the taught module and the lifelab day are designed with a focus on the science behind the messages about positive health behaviours, such as diet and pa, for the adolescents now, in adulthood and their future offspring, with the aim of promoting personal plans for change. the each-b research trial aims to recruit approximately 2300 secondary school students aged 12–13 years from 50 schools (the clusters) from hampshire and neighbouring counties. participating schools will be randomised to either the control or intervention arm. the intervention will be run during two academic years, with continual recruitment of schools throughout the school year until the sample size is reached. the schools allocated to the control arm will receive normal schooling but will be offered the intervention after data collection for the trial is complete. an economic model will be developed to assess the cost-effectiveness of the each-b intervention compared with usual schooling. discussion: adolescents’ health needs are often ignored and they can be difficult to engage in behaviour change. building a cheap, sustainable way of engaging them in making healthier choices will benefit their long-term health and that of their future children. trial registration: isrctn 74109264. registered on 30 august 2019. each-b is a cluster randomised controlled trial, funded by the national institute for health research (rp-pg-0216-20004). the nhs long term plan sets out a prevention agenda in the uk aimed at reducing the risk of developing noncommunicable diseases (ncds) such as cardiovascular conditions and type 2 diabetes [1] . insufficient exercise and poor dietary quality are common and are linked to increased risk of ncds. ncds place a heavy burden on society, hospitals and community health services, costing the nhs £7 billion a year [2] . uk adolescents have poorer diets than other age groups, and fewer than 20% meet physical activity guidelines [3, 4] . intervening during adolescence to support better health habits can bring a triple benefit: to the immediate health and wellbeing of the young person, to their own health in adulthood and to the health of the next generation [5] [6] [7] [8] [9] . it is well-established that improving the dietary quality and nutritional status of both young women and young men before conception improves pregnancy and birth outcomes and therefore the long-term health of the offspring [10] [11] [12] . it has also been suggested that adolescence is a critical period during which optimal nutrition could mitigate the effects of poor fetal and infant nutrition [13, 14] . as a critical period of both physical and social development, adolescence is the time during which the physiological, mental and behavioural foundations of long-term health are consolidated. peak muscle and bone mass as well as cardio-respiratory fitness are reached during adolescence, and these physiological processes are both nutritionally sensitive and predictive of later health [15] [16] [17] . in addition, widespread brain re-modelling during adolescence leads to a large increase in cognitive ability [18] . adolescence is also a key time for the development of executive function and the capacity to make independent choices, follow them through and achieve goals, as well as the ability to form healthy social networks. lifelong behaviour patterns are established in adolescence, including choices about diet and physical activity (pa) [13] . adolescence is a challenging time to intervene to improve health behaviours for both psychological and physiological reasons. adolescents find it difficult to engage with the long-term consequences of their lifestyle choices. developmental changes in brain structure leave them sensitive to emotional and social influences and to prioritising the immediate over the long-term; brain pathways involved in decision-making processes do not mature fully until early adulthood [14, 19] . systematic reviews suggest that motivated and engaged adolescents can improve their health behaviours [20] . however, little is known about precisely how to motivate and engage adolescents in sustaining positive changes long term [21, 22] . the latest research evidence strongly indicates that successful interventions with adolescents are as follows: (i) multi-component, (ii) involve schools, (iii) engage and motivate adolescents to change their health behaviours and (iv) involve social support from friends and parents [23, 24] . in addition, digital platforms show potential as complementary features in complex interventions targeting health behaviour change and are particularly relevant to this age group. approximately 83% of 12-15 year olds owned smartphones in 2018, and 99% spent an average of 20 h a week online [25] . key strategies for effective engagement with digital interventions are recognised to include co-designing interventions with adolescents, the personalisation of interventions and connectivity to peers and the user's wider social networks [26] . it is increasingly recognised that interventions need to facilitate collaboration between different agencies such as schools, community and parent groups and not rely on one setting, such as the school or family. interventions to improve adolescents' diet and pa have been implemented with varying success; effective engagement with, and motivation of, adolescents remains a pertinent issue. gender-specific issues should not be overlooked, and positive effects post-intervention may not be apparent in the short-term, making medium and longer-term measures important [24, 27, 28] . many interventions favour combining health and nutrition education with behavioural skills training, even though evidence suggests that adolescents are not ignorant about the health implications of their food choices and pa habits, nor are they motivated by health in the distant future [29, 30] . recent research has suggested that interventions designed to support adolescent health may be more engaging and successful if they align health agendas with adolescents' own values and priorities [30, 31] . each-b is designed using a person-based approach [32] [33] [34] with extensive co-creation to maximise alignment with adolescents' own values in order to make the intervention both engaging and effective. the views and input of parents and adolescents in the age range of each-b's target population have been continually sought and incorporated into the trial design through extensive engagement work with local schools, youth groups, and through lifelab's young ambassadors scheme. 1 in addition, two advisory groups have been set up to ensure the intervention design and delivery are acceptable to parents of young teenagers and to the young people themselves. a number of 'game jams' involving approximately 300 adolescents have been run throughout the development phase, in order to ensure the app reflects the values and priorities of the intended user group [35] . aligning an intervention design with adolescent values and using fun, engaging methods of delivering behaviour change support as part of a multi-component, school-based intervention improves diet and pa habits of secondary school students. the aim of this cluster randomised controlled trial is to evaluate whether each-b, a complex intervention designed to engage, motivate and support adolescents aged 12-13 years, improves their dietary quality and pa habits. each-b is a cluster randomised controlled trial using a 1:1 allocation within a superiority framework. the intervention consists of three-components: (1) face-to-face support from teachers trained in skills to support behaviour change, (2) engagement in the lifelab school-based education programme and (3) a digital intervention with games as well as peer-and parent-support features. we propose to evaluate each-b through a cluster randomised controlled trial. we plan to recruit boys and girls of middle academic ability in year 8 (aged 12-13 years) from 50 state secondary schools/academies (approximately 2300 students) to take part in the trial. year 8 is the second year of senior school in the uk and was chosen to take part in each-b in consultation with schools for two key reasons: schools are better able to deliver the intervention at this time, before students start their gcse curriculums in year 9 and timetabling becomes more difficult; adolescents in year 8 often have increased levels of independence in terms of food choices whilst travelling to and from school alone or with friends. schools in hampshire, uk, and the surrounding counties will be eligible to take part. hampshire is a large county (pop. 1.4 million) in the south of england with a wide range of socioeconomic profiles. some rural areas of hampshire are affluent, but the two major cities southampton and portsmouth are in the most deprived quintile of local authorities in the uk [36] . schools will be recruited from both rural and urban settings in order to reflect the diversity of the population (see the 'randomisation/blind ing' section for more on randomisation procedures). each school will be randomly allocated to either 'control' or 'intervention' status. of the schools recruited, 25 will therefore be intervention schools where two classes of year 8 students will complete the lifelab module, be offered support from teachers trained in skills to support health behaviour change and receive the digital intervention. the other 25 schools will form the control group and will receive normal schooling. all state secondary schools and academies in hampshire and surrounding areas are eligible to take part in the each-b intervention trial. independent and selective schools including special schools and single-gender schools are excluded from taking part because by nature of being selective their inclusion could bias the study findings. 1 lifelab's young ambassadors scheme is a scheme whereby young people who visit lifelab with their school can sign up to be a young ambassador in order to support lifelab's aims and objectives by taking part in special activities including being consulted on new ideas as they are developed and worked up by the lifelab team. in late 2019, a successful pilot trial was run with 170 students from six schools in the southampton area, to test and modify the intervention. the intervention comprises: i) professional development for teachers including training in communication skills to support health behaviour change, known as 'healthy conversation skills' (hcs), explained in detail below ii) lifelab educational module comprising in-school teaching of nine science lessons linked to the english national curriculum and a hands-on practical day visit to lifelab, held part way through the module iii) a personalised digital intervention (the 'app') with social support and game features the each-b intervention includes professional development (pd) for all teachers involved in delivering the life-lab educational module. the 1-day pd training course takes place at lifelab and focuses on science education relevant to the implementation of the nine lessons in school. it offers access to online support materials which describe the underpinning science. teachers are trained in hcs [37, 38] to engage with their students in making plans to improve their diet and/or activity levels via a personal 'lifelab pledge'. teachers are trained how to support their students to keep their pledges, and how to use the digital intervention, through asking open questions and listening rather than telling. an additional hcs training session will be offered to the whole staff body in intervention schools to enhance the opportunity for adolescents to be supported at school to improve their health behaviour. hcs training was developed in southampton to provide communication skills to support behaviour change. these skills were designed in the first instance for health and social care practitioners to use with their patients and clients, but have since been adapted to the training of teachers to enable them to better support behaviour change in their students. while health promotion is not seen as a core requirement of a teacher's role, we have seen high levels of engagement from teachers throughout the development work and each-b pilot trial. it is widely acknowledged both in the scientific literature and by schools that diet and pa behaviours are significant factors in both academic performance and student wellbeing and there is growing evidence that health and health behaviours have measurable consequences for attainment [39] . being more physically active at age 11 is associated with higher attainment at gcse, while being obese at age 11 is associated with lower attainment [40, 41] . children from more disadvantaged backgrounds are more likely to be overweight/obese, have poorer diets and be less physically active. being overweight/obese can reduce children's self-esteem, which may lead to lower educational attainment and behavioural problems [39] . therefore, schools and teachers are keen to learn skills that enable them to support students to eat well and be more active. the use of hcs encourages people to reflect on behaviours that they would like to change, in many cases making the unconscious, habitual behaviours conscious and therefore amenable to deliberate change. hcs trains people to use five key skills: (1) creating opportunities for having healthy conversations; (2) asking open 'discovery' questions that lead people to explore and find their own solutions; (3) listening more than talking and so empowering people to identify and take control of their own behaviour change; (4) reflecting on practice in order to be more effective; and (5) supporting goalsetting using smarter 2 action planning, providing people with a sense of change and progress. these skills were originally developed in collaboration with local health service commissioners in southampton, whose needs-assessment found that their healthcare providers lacked confidence to support clients to improve their diets and lifestyles [42] . hcs training recognises that skills to support behaviour change need to go beyond education and instead empower individuals to take control of their health behaviours and to problem-solve. as with motivational interviewing, the training offers an approach to supporting behaviour change that is based on the understanding that giving people information is insufficient to change their behaviour; they must also be motivated to change and have the tools to implement that change. hcs training is philosophically underpinned by bandura's social cognitive theory of the socio-environmental and personal determinants of health [43] . self-efficacy is a central construct in this theory and describes an individual's belief that he or she is capable of carrying out a specific behaviour, which implies that he or she also has the knowledge and skills to do so. hcs are designed to increase self-efficacy through empowering problem-solving, and employ behaviour change techniques [44, 45] intended to support small changes in behaviour, leading to acquisition of mastery skills which bandura proposes as a means of raising self-efficacy. training in hcs is designed to increase the self-efficacy and hence build the capacity of practitioners and clients and, in doing so, change the ethos of those practitioners and their organisations to one that empowers change. the each-b intervention is designed to operate both at the level of individual behaviour change and at the level of changing the culture of schools to trigger automatic as well as reflective processes underlying behaviour change [37, 38, 46, 47] . the lifelab educational module aims to engage adolescents with the knowledge and understanding needed to enable them to make appropriate health choices-their health literacy-and to motivate them to change their dietary and pa behaviours. the theme of the module is 'me, my health & my children's health', and it is delivered in an interactive and highly engaging format which sets scientific knowledge into a relevant and accessible context for this age group [4] . the educational module is designed to be delivered as four pre-and five post-lifelab visit lessons delivered in science classes during the school day. the materials used in the educational module are explicitly linked to the english national curriculum, embed the messages of the lifelab visit and have been updated specifically for the each-b trial. for example, an additional lesson focusing on the influences of the food environment on healthy lifestyle choices has been added, in order to encourage the adolescents to critically analyse their own food environments and the influence these may have on their dietary behaviours. health messages in the module are linked to both the hands-on practical activities the students will carry-out on the day visit to lifelab and to the school-based activities. this approach is intended to ensure that the adolescents understand the long-term implications of their current diet and pa on their future health, their children's health and on the risk of ncds for both. halfway through the lifelab educational module in school, the students and their science teacher have a day visit to the purpose-built laboratory facility, based in southampton general hospital. the visit combines a mixture of hands-on practical work, reflection on lifestyle choices and learning about the science behind health messages. activities include: experiencing a variety of ways to measure health including assessing carotid artery blood flow and structure using ultrasound, measuring body composition, performing lung function tests, training in cpr and testing grip strength and flexibility extracting their own dna and carrying out gel electrophoresis experiments that illustrate how a healthy diet can induce epigenetic changes that alter dna structure and are passed from parents to offspring, with implications for cardiovascular and lifelong health for themselves and their children small group discussion sessions with scientists based at the hospital, to introduce students to the range of career options in scientific disciplines. at the end of the lifelab visit, and with support from lifelab staff, students are encouraged to make a 'pledge' about a positive change for their own health. students also download the each-b app onto their personal devices during the day (see below). the digital intervention will be in the form of a mobile phone application (app) with game features. it has been developed using a person-based approach to intervention development, combined with user-centred design principles for digital game design and a participatory design process. the design of the game is underpinned by self-determination theory and employs a range of behaviour change techniques [33, 44, 45] . during the lifelab visit, students will be asked to download the app onto their personal mobile devices (android or ios) and log in. any student without a personal device will be given instructions for downloading the app at home via a shared family device. the app will involve creating a character and choosing games, quizzes and challenges to complete. players can choose challenges and none are compulsory. the app will allow players to connect with each other if they wish. parents/carers of students in the intervention will also be offered a companion app to help them support their adolescent in making healthy lifestyle choices. the parent app includes information about the different elements of the app developed for the young people taking part in the intervention. it also contains ideas, suggestions and prompts as to how parent and adolescent can join forces to improve food choices and activity levels for the whole family. all outcomes will be measured twice, once at baseline and again 12 months later at follow-up. the trial has co-primary outcomes for dietary quality and pa. dietary quality will be assessed by a 20-item food frequency questionnaire (ffq). this ffq has been developed specifically for use with adolescents using data for boys and girls aged 11-18 years who took part in the national diet and nutrition survey. principal component analysis was applied to these data in order to identify 20 indicator foods which best describe better and poorer dietary quality of uk adolescents. this ffq has shown good comparison with important nutritional biomarkers including 25-hydroxy vitamin d, total carotenoids, serum folate and vitamin c. using geneactiv™ accelerometers pa will be assessed as minutes of daily low, moderate and vigorous physical activity (lmvpa), also described as total pa [48] . at baseline and again at the 12-month follow-up, geneactivs will be worn for 7 days and the output data will be averaged over this period, or the maximum period of valid data. secondary outcomes for dietary quality are as follows: usual portions in the past month of water, sugar sweetened beverages (ssbs), chips and crisps and usual portions of fruit and vegetables consumed in a typical day. the number of portions of fruit and vegetables are analysed separately to estimate daily fruit and vegetable consumption for each adolescent [49] . categories of pa will also be assessed as secondary outcomes, namely average acceleration, intensity gradient, sedentary time, light pa, light to moderate pa, moderate to vigorous pa, lmvpa 1-min, lmpa 1-min and mvpa 1-min. the categories of '1-min' restricts to activity that has a minimum of 1-min bout duration. all pa outcomes (primary and secondary) will be analysed separately for activity at the following times: weekdays, weekends, during school hours and during out-of-school hours. additional secondary outcomes are as follows: bmi zscores, with and without adjustment for pubertal status as indicated by standing height, sitting height and weight [50] ; self-reported frequency of pa from a modified version of the youth physical activity questionnaire (ypaq) validated for use in 12-13 year olds [51] ; behavioural self-regulation and self-efficacy for healthy eating and pa; and quality of life and wellbeing measured by two age-appropriate tools: the child health utility 9d (chu9d) [52] and the cantril ladder [53] . behavioural regulation and self-efficacy for pa will be assessed by the behavioural regulation for exercise questionnaire [54] and the pa section of the self-efficacy for healthy eating and physical activity measure (se-hepa) [55] . behavioural regulation and self-efficacy for diet will be assessed using the recently developed confidence and behavioural autonomy (cba) scale. this is age-specific and has been validated against the healthy eating scales of the se-hepa and the treatment self-regulation questionnaire (tsrq) [56] . a schematic schedule of enrolment, interventions and assessments is shown in fig. 1 . unpublished analysis of earlier data from lifelab indicates an intra-school (class) correlation coefficient of 0.035. forty-six schools each sending two classes amounting to approximately 50 students from each school and 2300 students in total will provide 90% power at a 0.025% significance level (accounting for two primary outcomes) to detect a 0.25 sd difference in diet quality score or minutes of total pa in intervention and control schools. comparable effect sizes have been considered in other health interventions as meaningful in terms of change in health behaviours, and our level of 0.25 sds falls in the mid-range of effect sizes reported in a meta-synthesis of meta-analyses of behaviour change interventions in the general population [57] . we will recruit two year 8 classes (12-13 years) from 50 schools allowing for drop-out, though in previous lifelab studies only one school has ever dropped out. to minimise bias from loss of students to follow-up, we will request class lists for each participating class, so that missing participants at each stage of the follow-up can be identified and included in secondary analyses and process evaluation assessing uptake of the intervention. recruitment for each-b began in september 2019 and will run for 2 years, with data collection taking place at schools at baseline and again 12 months later. the life-lab team has worked with schools for many years and good systems for recruiting schools have been developed, so recruitment difficulties are not anticipated. we appreciate that control schools will not want to miss out on the intervention and therefore all control schools will be offered a visit to lifelab the following year. the schedule of enrolment for the trial is shown in fig. 1 . schools will be recruited through a range of methods including presentations at relevant local meetings such as the secondary heads of science forum meetings, and letters sent to head teachers and heads of science of eligible schools in the recruitment catchment area. the recruitment pack for each-b includes a cover letter and information sheet for the school, offering basic information about the trial and explaining how the experience will differ for control and intervention schools. schools are then offered a meeting with the each-b research team at which further details are discussed and any questions answered. this meeting will take place with the head of science and a member of the senior leadership team at the school, at a time to suit them. it is also an opportunity for the research team and the school staff to establish how the intervention will run in the school, if it is allocated to the intervention arm, as each school operates differently in terms of timetabling science classes. schools will be asked to allocate two middle ability year 8 classes to participate in the trial totalling approximately 50 students. the teaching programme is designed for students in this age group and of all ability levels; there are no exclusion criteria for students. for students who may require more input (those who have english as a second language, for example), we provide support for schools in planning delivery of the module. specifics are discussed at the teachers' pd day. schools will already have in place provision for these students, and so it is a matter of ensuring that the lifelab materials are accessible by all participating students. following the meeting at school, the head teacher is asked to sign a consent form confirming they wish to take part, that they understand the trial procedures and to name the two classes that will participate. after signed agreement from the schools has been obtained and the classes taking part have been identified, schools will be randomised to receive usual schooling (control) or the each-b intervention (lifelab programme, hcs training for teachers, and access to the digital intervention) (see fig. 1 ). we will use a minimisation procedure developed by the southampton clinical trials unit (tenalea), which aims to achieve a balance of schools in the two arms based on the following three criteria: -the proportion of students in the school receiving free school meals (cut-off > 24%); -the proportion of students in the school achieving l5 gcse (equivalent to a high 'c' grade) in english and maths (cut-off > 40%); -whether or not the school already participated in the full lifelab programme in the previous 2 years. the randomisation is administered through a webbased secure system to which the each-b team submit the details of schools who have consented to participate. these are sequentially numbered and the allocation to intervention or control is then reported to the investigators. blinding from this point onwards is not possible except of the statisticians who will be analysing the data. many schools we recruit will have previously been involved in lifelab. contamination of the intervention effect is unlikely to occur as the year 8 students taking part in each-b will not have visited lifelab before, and except for siblings, they will generally have limited contact with older children in the school. it will not be possible to blind schools and their students to their allocation due to the nature of the intervention. primary and secondary outcome data will be collected at baseline and follow-up visits by research staff to schools, conducted during class time. standing and sitting height and weight will be collected by trained research nurses from the clinical research facility at the southampton nihr biomedical research centre (sbrc). these measures will be used to derive body mass index z-scores and biological maturity [49] . all researchers and research nurses working on the each-b trial will be trained in trial-specific procedures and be required to complete appropriate safeguarding and eating-disorder training. questionnaire data will be collected through participant completion of questionnaires on ipads during the baseline and follow-up visits to schools. the class will be divided into small groups of 7-8 students working with one member of the research team who will act as a facilitator. before students begin completing the questionnaires, the facilitator will use a trial-specific standard operating procedure to explain key points about the questionnaires and will remain with the group throughout the session to answer any questions that might arise. geneactiv™ accelerometers will be distributed to participants by trained research staff during the data collection sessions at both time points. the devices will be programmed to automatically start measuring at midnight on the first day of data collection and stop measuring precisely 7 days later, in order to capture both weekend and weekday activity. a sampling frequency of 100 hz will be used. participants will be asked to keep the device on their non-dominant wrist for seven full days, preferably without taking it off at any point. seven days after the baseline data collection visit, schools will be asked to return the geneactivs to the research team via courier or another secure method. after data collection visits to schools, all data will be downloaded from the ipads via a secure sockets layer (ssl) that encrypts the data before sending it and storing it in the database. the database itself is kept on a university server. all questionnaire data will be kept in accordance with general data protection regulations (gdpr), university of southampton data protection policy and in accordance with the protocols of the mrc lifecourse epidemiology unit leu). the data will be stored in password-protected computers by the research team and only accessible by them. data will be stored in access databases and managed with support from the data management staff of the mrc leu, who have extensive data management expertise and manage data from more than 200 studies. after the trial is complete, anonymised data will be available to other researchers under our data sharing protocols. identifying information will be collected about participants, purely for the purposes of matching baseline and follow-up questionnaires. all identifying information will be stripped from the rest of the data after linkage is complete and will be stored separately. it will only be kept in case a further follow-up is planned. data will be analysed using stata, spss and mplus. the primary analyses will be according to the intention-totreat principle, comparing dietary quality and pa levels in the intervention and control groups using mixed effects linear regression to account for clustering within schools. the main analysis will compare these outcomes at baseline and at 12 months follow-up. although randomised at the level of schools using a minimisation algorithm, there may still be disparities between the intervention and control participants at baseline. these will be assessed prior to analysis and relevant confounders will be incorporated in the models; factors to be considered include gender, exact age at recruitment and household area of deprivation using the income of deprivation affecting children index (idaci) score [58] . adjustment for baseline dietary quality and pa levels will be included in the relevant models to allow an assessment of change from baseline. sensitivity analyses will examine effects of missing data, and multiple imputation will be used where appropriate, accounting for the clustered nature of the data. comparisons for secondary outcomes will also be modelled using mixed effects linear regression, with the use of binary models for binary outcome variables. mixed effect logistic regression will be used for rare outcomes and mixed effect binary regression (or poisson regression with robust variance if the binary regression models fail to converge) will be used for outcomes that occur in more than 10% of students. we will then conduct a mediation analysis to examine the role of these secondary factors in mediating the effect of the intervention on primary outcomes. the main analyses will be conducted using the latest available version of stata. planned subgroup analyses will focus on whether there are different effects for boys and girls, differing ethnicities, seasonal variation, idaci score and estimated biological maturity in outcomes. we will also determine the effect of each-b on outcomes for those who fully engage with the digital intervention (per protocol analysis) and assess uptake of the digital intervention by gender, ethnicity and idaci score. complier average causal effect (cace) modelling techniques will be used to examine factors that predict engagement with intervention components and to examine intervention effects specifically for students who engaged with those components. as this is a cluster randomised controlled trial, many of the assumptions underlying this method are unlikely to be valid, most obviously the independence of the participants [59] . these assumptions will be assessed and methods of analysis developed appropriately. the cace analysis will be performed using mplus. data monitoring will be the responsibility of the trial team at the mrc leu. the steering committee will receive regular data reports as part of their bi-annual meetings. due to the low risk nature of the trial, a separate data monitoring committee is not deemed necessary. we are not expecting the trial to give rise to any adverse events or harms. however, a risk assessment was completed and submitted as part of the ethical approval process. all staff involved in visiting schools have the enhanced level of dbs to work with children, are trained in safeguarding and awareness of eating disorders and have basic levels of awareness about dealing with someone who may become anxious for any reason during a data collection visit. using the mrc guidance on process evaluation of complex interventions [60] , focusing on the programme logic model, we will use mixed-methods to examine (i) implementation, (ii) context and (iii) mechanisms of impact of the each-b intervention. i) implementation: we will examine how intervention delivery is achieved and what is delivered (fidelity, dose, adaptations and reach) by, for example, monitoring downloads of the digital intervention on lifelab day as a proportion of those eligible, frequency of access to the digital intervention, as well as conducting structured, qualitative observations of teacher/student interactions, and teacher/student interviews. ii) context: we will assess context at school level by interviewing relevant staff about other activities and factors that may affect how the intervention was implemented and how it worked. the wider policy context will also be assessed at local and national levels by considering relevant healthy living initiatives or campaigns and their potential influence. iii) mechanisms of impact: we will conduct interviews with students, teachers and parents to explore their experiences of and engagement with the intervention as a whole and use in-app telemetry to explore usage of the digital intervention. some interviews will be carried-out with specific subgroups of students to ensure that the intervention is not stigmatising. analysis of the qualitative data collected as part of the process evaluation will be conducted with a view to achieving a comprehensive understanding of the way in which an intervention like each-b is implemented and how that relates to the outcomes. thematic analyses of all qualitative data from the process evaluation will be undertaken. structured, qualitative observations of teacher/student interactions and interviews with students, teachers and parents to explore their experiences of and engagement with the intervention will be analysed using various forms of content analysis. for observations of teacher/student interactions, structured record forms will be designed to monitor use of hcs. interviews will be audio-recorded, transcribed verbatim and analysed using inductive thematic analysis and a standard methodology [61] . initial codes will be discussed between coders to reach agreement on themes, and then discussed with the wider research team and ppi panels. broad themes will then be broken down to identify commonly expressed themes and unusual cases. approximately 10% of the data will be coded by two team members to check that the coding scheme is identifying all the themes and concepts and that there is a shared understanding of what they are. findings will be used to assist with interpretation of the trial outcomes and to illuminate mechanisms through which the intervention has its effect. a model will be developed to estimate the costeffectiveness of each-b compared to usual schooling. the model will extrapolate short-term observed effects on diet, pa and quality of life (chu9d) to estimate future health impacts and societal costs. there are many risks associated with poor diet and low pa over the life course, including increased incidence of a range of ncds and adverse social, economic and well-being outcomes. we will focus on four key risks for which there is good evidence of a short to medium-term impact: incidence of type 2 diabetes, mental health, low birth weight and future loss of earnings [62] . health outcomes will be quantified using quality-adjusted life years (qalys), including direct effects of diet and pa on quality of life (chu9d), as well as losses associated with type 2 diabetes, depression and low-birth weight pregnancies. costs will be estimated from a societal perspective, including costs to schools, local authorities and the nhs and loss of earnings for individuals. costs and qalys will be estimated over a time horizon of 20 years in the base case, discounted at uk recommended annual rates [63] . a range of sensitivity and scenario analyses will be conducted to assess uncertainty of the model predictions. this will include alternative assumptions about the persistence of observed effects on diet quality, pa and quality of life from the trial. this trial will estimate the effectiveness of a complex intervention to improve diet and pa in adolescents, designed to have reach and affordability. if it proves effective, the intervention could be rapidly and inexpensively disseminated to all secondary school students attending lifelab from across the wessex region. potential for the intervention to be introduced widely across the uk will be explored. some elements of the intervention will be easier to translate than others. in areas where there is already an educational intervention providing initial engagement for adolescents in thinking about their health, educators could be trained in communication skills to support behaviour change. the supplementary digital intervention is low-cost and sustainable. if successful in supporting behaviour change, the intervention has potential for both immediate impact on adolescents' health and well-being and for improving the health of the nation for generations to come. the intervention is designed to deliver outcomes aligned to the local authority's sustainability and transformation plan. as such, it represents an attempt to meet the need to provide preventive methods that can easily be up-scaled and that deliver technological solutions for major health issues. trial findings that will have wide application and impact include improvements in understanding how best to intervene with maximal effectiveness and cost-effectiveness to improve adolescent health behaviours, and to engage, and sustain the engagement, of adolescents. sub-group analyses of data will allow tailoring of the intervention to specific groups, e.g. the most disadvantaged, hardest to reach, or boys as distinct from girls. the programme provides information about the value of, and best practice in, co-creation of initiatives with adolescents and our understanding of mechanisms of creating change with adolescents. recruitment for the rct initiated in september 2019 and was due to be completed by june 2021. the trial was halted in march 2020 due to the closure of schools in response to the covid-19 global pandemic. the trial team plans to restart the trial in late autumn 2020. the trial protocol is version 1 date 21 august 2019. the study has been registered on the isrctn database (isrctn74109264, registered 30 august 2019). the research sponsor is the university hospital southampton nhs foundation trust. the each-b research management team (comprising sts, meb, jvs and hmi) and research theme leads (jb, kwt and the management team) meet regularly to monitor the trial, while the remaining co-applicants and programme steering committee provide oversight through bi-annual meetings. we do not anticipate any protocol amendments, but may have to make changes as a consequence of the covid-19 pandemic. in the instance of a protocol amendment being required, we would discuss this with the programme steering committee, the funder, the sponsor and ethics committee and any participants affected. the main output from this research will be a fully developed, replicable intervention to improve adolescents' dietary quality and pa levels. we will determine the success of co-creation processes with adolescents, short-, medium-and long-term health benefits from intervening in adolescence, intervention cost-effectiveness, including reach/affordability and feasibility of rapid/inexpensive roll-out into routine practice in schools. in line with funder requirements, at the end of the trial after all statistical analyses are completed, we plan to grant public access to the full trial protocol, the anonymised dataset and statistical code used. dissemination pathways include close collaboration with stakeholders, including young people, feedback of findings to teachers and students, interactive workshops with stakeholders; conference presentations and a series of papers in open access peer-reviewed journals; links with professional societies and policy-makers; and regular press releases. all participants' data will be stored anonymously following the university of southampton guidelines. confidentiality and linked anonymity will be assured. information will not be reported in a way that would allow an individual participant to be identified. participants will only be known by id number when the data are reported. participants' identifying information will be stored separately from the data collected, but need to be kept to ensure linkage between the baseline and follow-up data. all interview data will be kept in accordance with the data protection law (including gdpr) and university of southampton and uk medical research council policies. data will be stored on password-protected computers by the research team and only accessible to them through the data manager. ancillary and post-trial care there are no expected adverse events or harms associated with the trial. no specific post-trial care is planned, but in an event where a participant was in any way adversely affected, the study team would work closely with the school and parents of the participant to ensure appropriate support is offered. all authors took part in the design of the study. meb, hmi, kwt, sts, scs and mb carried out pilot work and were involved in the conception, development and delivery of the programme of work. meb and hmi are principal investigators and together have overall responsibility for the each-b trial and wrote the protocol for the study. lb, dml and kwt were involved in the design, development and delivery of the teaching programme of work, including the pd programme for teachers, and wtl was involved in the design and delivery of the pd programme for participating teachers and leads on the hcs components and evaluation. meb, hmi and jb were involved in the design of the cluster randomised trial and concurrent process evaluation. meb, sts, scs, hmi and cv were involved in the design and validation of the research questionnaires. hmi is the statistician on each-b. pc, mb, hmi and sts manage the data for this study. jc, cc, dc, pl, mh and kg are study collaborators and were involved in the conception and development of the study. dl has advised on the design and development of the physical activity measures and is responsible for the analysis of the physical activity data. jl, nk and oo are responsible for the health economic modelling and cost-effectiveness analysis of the interventions developed in this programme. all authors have contributed to the manuscript and approved the final submitted version. this research is funded by uk nihr programme grants for applied research (rp-pg-0216-20004). the views expressed are those of the authors and not necessarily those of the nihr or the department of health and social care. researchers working on this trial are also supported by the following funding sources: uk medical research council (mc_uu_12011/4), nihr southampton biomedical research centre, wessex heartbeat and public health england. lifelab has also received research funding from the british heart foundation, the wellcome trust, cancer research uk, research councils uk, the bupa foundation, the primary science teaching trust (formerly the astra zeneca science teaching trust) and the epsrc (via the uos pathways to impact funding scheme). study sponsor and funder have had no role in study design and will have no role in collection, management, analysis or interpretation of data; the writing up of a final report; and the decision to submit papers for publication, and they will not have ultimate authority over any of these activities. data sharing is not applicable to this article as it is a protocol of an ongoing study and no data is reported. all anonymised datasets from the study will be deposited in a publicly available repository after the trial has ended. ethics approval and consent to participate full ethical approval was granted on 21 july 2019 from the university of southampton's faculty of medicine ethics committee (ethics id 49226). once the school has agreed to participate, the head teacher has signed the consent form, and the randomisation process is complete, the appropriate trial documents for parents and students are provided for the schools to disseminate. two versions of the letter for parents and the participant information sheets have been produced: one for intervention schools and one for control schools. in both cases, parents and students are provided with contact details of the research team in case they have questions about taking part in the research trial. for both intervention and control schools, consent will be opt-in and collected by the schools prior to any research data being collected. in keeping with good practice, the consent form for intervention schools requires parents to initial boxes for each part of the intervention to ensure they understand and consent to each part separately. in all cases, student assent is also required and it is made clear that taking part is voluntary and a student or parent can withdraw their assent/consent at any time without giving a reason. the consent documents are collected by the study team at the baseline visit to schools and are thereafter stored securely at the mrc leu. no details, images or videos relating to an individual person are included. model consent forms will be provided on request. competing interests kg has received reimbursement for speaking at conferences sponsored by nutrition companies and is part of an academic consortium that has received research funding from abbott nutrition, nestec and danone. the university of southampton has received an unrestricted donation from danone nutricia to support lifelab's work with schools. wendy lawrence has received funding from danone nutritia early life nutrition for training and presentations. cc has received lecture fees and honoraria from amgen, danone, eli lilly, gsk, kyowa kirin, medtronic, merck, nestlé, novartis, pfizer, roche, servier, shire, takeda and ucb outside of the submitted work. outside of the submitted work, cv has a non-financial research relationship with a food retail company and maintains independence in all evaluation activities. this article, however, is not related to this relationship. the nhs long term plan the economic burden of ill health due to diet, physical inactivity, smoking, alcohol and obesity in the uk: an update to 2006-07 nhs costs ): a survey carried out on behalf of public health england and the food standards agency. london: public health england engaging teenagers in improving their health behaviours and increasing their interest in science (evaluation of lifelab southampton): study protocol for a cluster randomized controlled trial longitudinal tracking of adolescent smoking, physical activity, and food choice behaviors tracking of obesityrelated behaviours from childhood to adulthood: a systematic review the international federation of gynecology and obstetrics (figo) 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interventions for improving the diet and physical activity behaviors of adolescents a meta-analytic review of obesity prevention programs for children and adolescents: the skinny on interventions that work autonomy and control: the coconstruction of adolescent food choice harnessing adolescent values to motivate healthier eating a values-alignment intervention protects adolescents from the effects of food marketing intervention planning for a digital intervention for self-management of hypertension: a theory-, evidence-and person-based approach the person-based approach to enhancing the acceptability and feasibility of interventions the person-based approach to intervention development: application to digital health-related behavior change interventions idea jamming with teenagers. southampton: university of southampton london: ministry of housing, communities & local government healthy conversation skills: increasing competence and confidence in front-line staff making every contact count': evaluation of the impact of an intervention to train health and social care practitioners in skills to support health behaviour change the link between pupil health and wellbeing and attainment: a briefing for head teachers, governors and staff in education settings. london: public health england associations between objectively measured physical activity and academic attainment in adolescents from a uk cohort obesity impairs academic attainment in adolescence: findings from alspac, a uk cohort a mixedmethods investigation to explore how women living in disadvantaged areas might be supported to improve their diets health promotion from the perspective of social cognitive theory. psychol health the behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions from theory to intervention: mapping theoretically derived behavioural determinants to behaviour change techniques the effect of a behaviour change intervention on the diets and physical activity levels of women attending sure start children's centres: results from a complex public health intervention the southampton initiative for health: a complex intervention to improve the diets and increase the physical activity levels of women from disadvantaged communities estimation of fruit and vegetable intake using a two-item dietary questionnaire: a potential tool for primary health care workers an assessment of maturity from anthropometric measurements the validity of the youth physical activity questionnaire in 12-13-year-old scottish adolescents the development of a paediatric health related quality of life measure for use in economic evaluation: the child health utility 9d (chu 9d). sheffield: the university of sheffield reliability and validity of an adapted version of the cantril ladder for use with adolescent samples a modification to the behavioural regulation in exercise questionnaire to include an assessment of amotivation reliability and validity of the se-hepa: examining physical activity-and healthy eating-specific self-efficacy among a sample of preadolescents self-determination, smoking, diet and health meta-synthesis of health behavior change meta-analyses london: local government association cluster randomized trials with treatment noncompliance process evaluation of complex interventions: medical research council guidance using thematic analysis in psychology tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness the green book: appraisal and evaluation in central government we acknowledge sarah jenner, sara simao, daniel penn-newman, daniella watson and taylor morris who helped us collect preliminary data and develop research materials. kris tsenova created the artwork for the digital intervention and the education module. we are grateful to our ppi members ros horlock, paula twynham and rosie mackay for their advice and support. 1 mrc lifecourse epidemiology unit, southampton general hospital, university of southampton, southampton, uk. 2 publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-344491-93ggxzxu authors: husebo, bettina sandgathe; allore, heather; achterberg, wilco; angeles, renira corinne; ballard, clive; bruvik, frøydis kristine; fæø, stein erik; gedde, marie hidle; hillestad, eirin; jacobsen, frode fadnes; kirkevold, øyvind; kjerstad, egil; kjome, reidun lisbeth skeide; mannseth, janne; naik, mala; nouchi, rui; puaschitz, nathalie; samdal, rune; tranvåg, oscar; tzoulis, charalampos; vahia, ipsit vihang; vislapuu, maarja; berge, line iden title: live@home.path—innovating the clinical pathway for home-dwelling people with dementia and their caregivers: study protocol for a mixed-method, stepped-wedge, randomized controlled trial date: 2020-06-09 journal: trials doi: 10.1186/s13063-020-04414-y sha: doc_id: 344491 cord_uid: 93ggxzxu background: the global health challenge of dementia is exceptional in size, cost and impact. it is the only top ten cause of death that cannot be prevented, cured or substantially slowed, leaving disease management, caregiver support and service innovation as the main targets for reduction of disease burden. institutionalization of persons with dementia is common in western countries, despite patients preferring to live longer at home, supported by caregivers. such complex health challenges warrant multicomponent interventions thoroughly implemented in daily clinical practice. this article describes the rationale, development, feasibility testing and implementation process of the live@home.path trial. methods: the live@home.path trial is a 2-year, multicenter, mixed-method, stepped-wedge randomized controlled trial, aiming to include 315 dyads of home-dwelling people with dementia and their caregivers, recruited from 3 municipalities in norway. the stepped-wedge randomization implies that all dyads receive the intervention, but the timing is determined by randomization. the control group constitutes the dyads waiting for the intervention. the multicomponent intervention was developed in collaboration with user-representatives, researchers and stakeholders to meet the requirements from the national dementia plan 2020. during the 6-month intervention period, the participants will be allocated to a municipal coordinator, the core feature of the intervention, responsible for regular contact with the dyads to facilitate l: learning, i: innovation, v: volunteering and e: empowerment (live). the primary outcome is resource utilization. this is measured by the resource utilization in dementia (rud) instrument and the relative stress scale (rss), reflecting that resource utilization is more than the actual time required for caring but also how burdensome the task is experienced by the caregiver. discussion: we expect the implementation of live to lead to a pathway for dementia treatment and care which is cost-effective, compared to treatment as usual, and will support high-quality independent living, at home. trial registration: clinicaltrials.gov: nct04043364. registered on 15 march 2019. the world's population is rapidly aging as a result of fewer births and declining mortality rates [1] . the global health challenge of dementia is exceptional in size, cost and impact [2] . according to the world health organization, the number of people living with dementia is estimated to be 50 million worldwide, expected to almost triple by 2050 [3] . despite most people, also from a caregiver perspective, preferring to live longer at home, and to die there, if possible [4, 5] , about 30,000 of the estimated 80,000-100,000 persons with dementia (pwds) in norway reside in nursing homes [6] . the urbanization of our societies, in particular younger persons moving toward central areas and leaving their older relatives behind, underlines the need for cost-effective service collaboration to provide adequate treatment and care for the aging home-dwelling population. among the top ten causes of death globally, dementia is the only one that cannot be prevented, cured or substantially slowed [7] , leaving disease management, caregiver support and service innovation as the top priority for health policy-makers in the reduction of disease burden. due to expected positive interactions within the family, interventions supporting them as caregivers not only potentially lessen the caregivers' burden [8] , but could also be beneficial for the pwd (e.g. reducing neuropsychiatric symptoms and delaying nursing home admission) [9, 10] . as such, interventions supporting caregivers hold the potential for better overall resource allocation and utilization [11] . caring for a pwd comes at a high cost, both individually and at societal level. caregivers to pwds have lower perceived health and higher rates of mortality relative to their noncaregiver counterparts [12] . the effect of practical assistance and psychoeducational programs have been evaluated, but most single initiatives have fallen short in reducing the caregivers' burden [13] . the maximizing independence (mind) at home study undertaken in baltimore, usa, during 2008-2010 included approximately 300 home-dwelling persons with cognitive impairment or dementia in a parallel randomized multicomponent trial [14, 15] . this study showed that 18 months of care coordination through individualized care planning, implementation of a care plan, monitoring and reassessment had beneficial effects on the time to transition from home, number of dementiarelated unmet needs, quality of life (qol) and, importantly, a potentially clinically relevant reduction in selfreported number of hours spent on caregiving tasks, as a measure of caregiver burden [14, 15] . developing this model further, the mind at home-plus study included an additional 340 persons to evaluate the effect on longterm care placement, hospitalization and health-care expenditures of a 24-month homecare coordination program for pwd [16] . the mind at home-streamlined trial is now refining the intervention to investigate its impact on time to long-term care placement, needs, burdens and qol in pwds and their caregivers, as well as cost utilization [17] . results of the latter study are highly anticipated due to the potential for effective system-level approaches to dementia care [17] . yet, due to fairly large regional and cultural differences in care organization, there is a need for implementation studies in other countries to explore the generalizability of the program. a multicomponent intervention is not merely a discrete package of separate components, but a process of changing what complex systems do [18] . intervening within a complex system involves disrupting prior ways of working while introducing new ones [19] . the degree of complexity can be understood as a relative construct, defined by the number of components, diversity of the intended outcome, number of targeted organizational levels and level of skill required to deliver the intervention [20] , while additionally considering the interplay between context, setting and the implementation process [21] . in the cosmos trial, a randomized implementation hybrid trial carried out in norwegian nursing homes during 2014-2015, our group successfully developed, implemented and effect evaluated a multicomponent intervention addressing communication, systematic assessment and treatment of pain, medication review, organization of activities and safety [22] . overall, the intervention resulted in improved qol and activities of daily living (adl), in addition to a decrease in neuropsychiatric symptoms such as agitation and depression as well as a reduction in the number of medications used among nursing home residents [23] [24] [25] [26] [27] . to provide cost-effective care while securing the needs of pwds and caregivers represents a complex health challenge warranting multicomponent interventions implemented in daily clinical practice. aiming at systemlevel change, such interventions require stakeholder involvement as well as collaboration within and between different levels of primary and specialist health-care services, nongovernmental institutions, users and researchers, addressing the need for appropriate and coordinated cross-sector action. the live@home.path trial aims to develop, adapt, implement and effect-evaluate a multicomponent intervention for home-dwelling dyads of pwds and their caregivers, aiding them to stay safer, longer and more independently at home with cost-effectiveness. in this study, caregivers are defined as family or close friends, equaling informal caregivers. live@home.path is an acronym referring to each component of the complex intervention: learning, innovation, volunteer support and empowerment-at home pathway. the primary outcome is resource utilization. this is measured by the resource utilization in dementia (rud) instrument and the relative stress scale (rss), reflecting that resource utilization is more than the actual time required for caregiving tasks, but also how burdensome the task is experienced by the caregiver. importantly, the caregiver burden is individual, and may be related to economic hardship, anxiety, depression, hopelessness, impaired qol or lack of sleep and time for recreation. this individual perspective underlines the significance of user involvement, reflected in the trial's slogan: what matters to you? secondary outcomes include neuropsychiatric symptoms, number of adverse events, use of assistive technology, involvement of volunteers, qol and clinical global impression of change for the pwd as well as caregivers' depression, qol and work performance. the live intervention will reduce time and resources that caregivers spend in organizing and supporting pwds' daily activities, thereby reducing the caregiver burden. the live@home.path trial is a 2-year, multicenter, mixed-method, stepped-wedge randomized controlled trial (rct). we aim to recruit 315 dyads of home-dwelling pwds and their caregivers from the municipalities of bergen, baerum and kristiansand. based on experiences with two pre-projects-research council of norway sponsor code 261626 (uib) and 261605 (haraldsplass deaconess hospital)-the intervention was developed in collaboration with userrepresentatives, stakeholders and scientific partners from the scientific advisory board. to meet the requirements from the dementia plan 2020 by the ministry of health and care services [28] , we identified the "big issues" expected to facilitate support for home-dwelling pwds and their caregivers. as such, we combined and adapted existing knowledge rather than designing new components, contributing to service innovation in the health-care systems. the process was tailored to meet the standards of "development-evaluation-implementation", an internationally agreed approach for complex interventions launched by the uk medical research council [29] . at the start of the 6-month intervention period, the dyads will be allocated to a municipal coordinator, offering regular contact to assist in finding a pathway throughout the administrative trajectory of dementia care. the coordinator should hold a bachelor degree in health-related science (e.g. nursing, ergo or physiotherapy), and will make a minimum of two home visits, one immediately after the intervention start and the second after approximately 3 months. supplementary visits will be offered if needed, in addition to monthly telephone calls. during the intervention, the coordinator will introduce the dyads to the different stages of the live intervention: learning, innovation, volunteer support and empowerment (table 1 , fig. 1 ). all components will be carefully adapted to local conditions. learning a fruitful learning process is characterized by relevance, timing, confidentiality and reflection as well as fulfilment of expectations regarding content. the dementia plan 2020 [28] underlines increased knowledge at all societal levels as crucial for improvements in dementia care. a meta-analysis on the effectiveness of educational interventions supporting caregivers of communitydwelling pwds found a moderate impact on the caregiver burden, a small effect on depression, but no effect on transition to long-term care [30] . a norwegian multicenter randomized controlled trial found no reduction in depressive symptoms for pwds and caregivers after a 12-month psychosocial support program including formal education seminars [31] . yet coping had a positive impact on the caregiver burden in the latter study, possibly reflecting improved understanding of the caregiver situation [31] . in practice in the live@home.path: the coordinator will encourage and facilitate that both the pwd and the caregiver participate in local educational programs arranged by the municipality or the specialist health services several times yearly. as an example, the nationally established educational program for relatives of pwds is developed by the norwegian advisory unit on ageing and health [32] , and implemented for use in bergen, baerum and kristiansand. innovation innovation is understood as the application of better and more original solutions to meet new requirements, unarticulated needs or existing market needs, or employing established solutions in new areas, both technological, such as information and communication technology (ict), and organizational. crucially, the process will result in more effective products, processes, services, technologies or business models being made available for all, including markets, government and society [33] . as such, the live@home.path can be viewed as a service innovation, aiming at the development of a clinical pathway for dementia care. ict approaches in elderly care are broadly categorized as technical aids, cognitive intervention devices, and sensor and assistive living systems [34] . ict in dementia care holds potential for optimizing safety at home, reducing caregiver burden and, although the findings are not conclusive [35] , possibly also improving cost-effectiveness. yet we have limited knowledge about which type of devices are used, regarded as useful and requested by caregivers and pwds at different stages of dementia [36] . most important, this field requires a careful, individual risk-benefit assessment, as ict might negatively impact autonomy and privacy, and provide a false sense of safety. in practice in the live@home.path: the coordinator will assess and evaluate the usefulness of ict solutions already in use for pwds and caregivers and inform about additional relevant welfare technology available in the municipality. the participants will receive information about a newly launched online communication platform tailored to meet the needs of families organizing dementia care (jodacare©) [37] , and be informed about a web page with scheduled activities of relevance (fris-kus©) [38] . in bergen, the participants will be invited to test the prototype alight©, an application for tablets providing a "digital memory book" developed by soundio as and nks olaviken gerontopsychiatric hospital [39] . additionally, up to ten participants in bergen will be invited to test a prototype of the adapted communication platform in collaboration with the western norway university of applied sciences. underlining the aspects of service innovation, all data will be collected on tablets owned by the project group via the software surveyjs [40] . the live@home.path trial was selected as a pilot for the development and evaluation of this software, providing secure data transfer and storage on the safe server at the university of bergen for research project with sensitive data. after approval from the principal investigator, researchers affiliated with the project will be given access to the server, avoiding export of data and maintaining high levels of security [41] . volunteer support volunteer support is understood as any activities that involves someone spending time, unpaid and of one's own will, doing something that aims to benefit someone else outside their own families and households [42] . being important suppliers of unpaid support, it is estimated that volunteers contributed 142, 000 full-time equivalents (ftes) in norway in 2017 [43] . however, the majority are engaged in sports and culture, and representation in the elderly care sector is sparse [44] . volunteering among older adults reduces their depressive symptoms, improves self-reported health and functional performance, and increases survival [42, 45] . the volunteers additionally report better health through their own engagement [46, 47] . volunteerism has contributed to the development of the norwegian welfare system through identifying and providing solutions to societal challenges [48] , being formally integrated into core strategic plans in the health-care sector and being launched as a prioritized political strategy in elderly and dementia care in norway [49] . yet we have sparse knowledge about volunteer support schemes for homedwelling pwds. to provide better services, understanding of the dynamics, motivations and interactions in volunteerism in dementia care is required. in practice in the live@home.path: the coordinator will investigate pwd and caregiver attitudes toward volunteer support, and inform about volunteer services. if this is of interest, the coordinator will contact local volunteer coordinators for nonprofit organizations (the red cross [50] and the norwegian association for public health [51] ), aiming at the best possible match of volunteers based on assessment of preferences and wishes. empowerment empowerment in dementia care can be defined as "a confidence building process whereby pwd are respected, have a voice and are heard, are involved in making decisions about their lives and have the opportunity to create change through access to appropriate resources" [52] . the process of advanced care planning (acp) can increase empowerment for pwds and their caregivers [26, 27] , underlined by the norwegian policy guidance by the directorate of health on diagnosis, treatment and care for pwds [53] . pwds do not necessarily die from dementia, they die with it, and the life expectancy after onset of symptoms ranges from 4 to 11 years, depending on age and the presence of comorbidities [54] . the continuing process of communication should be initiated as early as possible in collaboration with the general practitioner as a comprehensive medical examination including revision of medications, enabling the pwd to clarify individual values and wishes for domestic and institutionalized treatment and care (i.e. "what matters to you?"). in practice in the live@home.path: the coordinator will schedule a minimum of one appointment at the general practitioner's office for empowering acp, including the issues of formal next of kin and guardianship. in addition, a systematic medication review will be undertaken to ensure use of medications in line with diagnoses and symptoms, utilizing recommended guidelines [25] . to evaluate the feasibility and the implementation strategy of the coordinators of the live intervention, a feasibility study was conducted during 2018-2019. sixteen dyads in bergen were assigned a coordinator for 6 months, participating in a minimum of two home visits and providing monthly follow up by telephone. one dyad dropped out after a few weeks of participation due to permanent placement in a nursing home, leaving 15 dyads followed by 2 coordinators for assessment. qualitative individual and focus group interviews utilizing a hermeneutic approach were performed with six dyads, three caregivers and the two coordinators as well as the coordinators' leader, exploring the usefulness of the coordinator function. this process revealed that the core feature of the coordinator was to support the caregivers in finding, applying and organizing support, and to provide emotional care, support and guidance. the objective of empowering the pwd in the decision-making processes was nonetheless particularly difficult to achieve. this finding was further incorporated into the live intervention for the stepped-wedge rct, with increased focus on the acp process and follow up of the gp [55] . implementation research is defined as the scientific investigation concerning the act of carrying an intervention into effect in the real-world setting [56, 57] . even a superbly designed intervention will fail to change practice if the process of implementation is futile. in the live@home.path trial, the implementation can be viewed as a two-stage process: first, from the research team to the coordinators; and, second, from the coordinators to the dyads. the first part encompasses all activities arranged by the research team empowering the coordinators to standardize the implementation of the intervention, such as seminars, development of written material and follow-up of coordinators during the intervention period. six months prior to the intervention start, kick-off workshops for all involved collaborators in the municipalities, including coordinators and affiliated specialized health services, will be arranged at all study sites, facilitating enthusiasm, collaboration and recruitment of participants. two weeks before the intervention start, a 2-day implementation seminar for the coordinators will be delivered by the research team at all study sites, training the coordinators through lectures, roleplay and discussions (see additional file 1). halfway through the 6-month intervention period, a 1-day midway evaluation workshop for the coordinators will be arranged, allowing for discussion of obstacles and pitfalls, which acts as a source for facilitating a more effective and standardized implementation. as a part of the intervention, the research team will contact each coordinator by telephone every 14 days to keep track of the process, discuss potential challenges and follow-up use of the checklist for implementation of the intervention. this ten-page pocket manual will contain a simplified howto-do description of the intervention components. it will be filled out for each dyad by the coordinator, registering time use and whether each of the distinct live components has been addressed during the intervention period. additionally, a 30-page tutorial will be developed as a comprehensible introduction to the rationale, method and practical aspects of the conduction of the trial, aimed for an audience not skilled in the research method. the second part of the implementation process encompasses the coordinator-dyad relationship. the coordinators are obliged to arrange a minimum of two home visits during the intervention period, and provide monthly contact by telephone. the checklist for implementation of the intervention will be used at every contact, and collected by the research team at the end of the intervention, providing documentation for the implementation process. in addition to the midway evaluation, a live conference will be organized for all coordinators at the end of the third intervention period, collecting data on their experiences of the suitability of the single components and the implementation process. additionally, at data collection after the intervention period, the participants will be asked if and to what extent they were offered the live components, and how often they were contacted by their coordinator. as such, if the live intervention fails to prove an effect on resource utilization, it will be possible to examine whether this is a result of the live components not being tailored to produce such an effect (i.e. that our main hypothesis was wrong) or whether it was caused by a lack of proper implementation. evaluation of the implementation process will further be investigated by conducting qualitative interviews with the coordinators as part of the mixed-method design. the required sample size was calculated to detect a difference of 7 h/week for the primary outcome rud. based on the literature, we assumed that the mean number of hours of informal care is 46 h/week with a standard deviation (sd) of 20 h/week [58] . with 80% power and a significance level of 5%, the required sample size was estimated to be 260 dyads. to allow for 20% loss to follow-up, a total of 315 dyads, equaling 105 per municipality, must be included. participants will be recruited from memory clinics at local hospitals, from municipal memory teams and after advertisements in general media such as newspapers, radio and tv in bergen, baerum and kristiansand. bergen is the second largest municipality of norway with approximately 280,000 inhabitants in 2018, baerum is ranked the fifth largest with 127,000 inhabitants, while the 92,000 inhabitants of kristiansand constitute norway's sixth largest municipality [59] . pwds are eligible for inclusion if they: are aged ≥ 65 years; are home-dwelling; have a minimum 1 h/week regular face-to-face contact with the caregiver; are diagnosed with dementia according to standardized protocol [60] ; have mini-mental state examination (mmse) score of 15-25; have a functional assessment staging test (fast) score of 4-7; and provide written informed consent. exclusion criteria are: participation in another ongoing intervention trial; or expected survival < 4 weeks. pwds are eligible for inclusion regardless of etiology of the dementia and presence of other disorders. caregivers are eligible for inclusion if they have a minimum of 1 h/week regular face-to-face contact with the pmd and provide written informed consent. as such, both the pwd and the caregiver will be included in the trial, representing a dyad. the mixed-method, stepped-wedge randomized control design data from all 315 dyads will be assessed every 6 months from baseline to the end of study period after 24 months, death or permanent residency in a nursing home-in total, five waves of data collection. the stepped-wedge randomized control design [61] implies that all participants will receive the 6-month intervention program during the study period, for which the timing of the intervention is determined by the randomization (fig. 2) . the control group constitutes the dyads waiting for the intervention at a given time during the study; this group will have access to health care and receive treatment as usual. criteria for discontinuing the intervention or participation are requested from participants to withdraw from the trial. the trial's user-oriented approach, aiming at minimizing the participant burden associated with follow-up visits, in addition to flexibility in scheduling of the visits are sought to promote retention and prevent loss to follow-up over the trial. no distinct adverse events are expected before the start of the trial or during the trial, while possible adverse events related to the change in prescribed medication during the general practitioner's medication review might occur. if so, they will be reported by the coordinators to the researchers, either immediately or at their regular follow-up every 2 weeks (physical meeting, by phone or by e-mail), in addition to feedback from the coordinator to the general practitioner. a statistician will randomly allocate the order of the intervention using block randomization; the dyads are randomized in clusters within each geographical location. the random sequence will be generated using a computerized random number generator undertaken for all three municipalities after the inclusion and baseline assessments are completed for all participants. research assistants, researchers conducting the analyses and other study personal conducting data collection will be blind to the randomization order and to the implementation process of the intervention. participants will not be informed of the intervention and implementation strategy to secure blinding until they are allocated to their coordinator during the intervention period. from this point of time, they become unblinded. given the practice change of the intervention, the municipality homecare services will be aware when their cluster enters the intervention period. when developing a pathway for dementia care, incorporating experiences and perspectives from the pwds and their caregivers is fundamental. in line with the involve framework [62], this trial is developed through user involvement from the conception of the idea, via design through the implementation phase. at the structural level, user involvement is secured via collaboration with the head of research at the norwegian health associations [51] , participating in the steering committee, and locally grounded by dementia coordinators in the municipalities. at the individual level, the centre for elderly and nursing home studies (sefas), responsible for conducting the trial, employs a user-representative as a co-researcher in a 10% position, who participates in the study's advisory board and working group. the mixed-method design [63] encompasses the integration of data from quantitative assessment of validated outcomes with material from qualitative interviews and participant observation. utilizing an exploratory hermeneutic design [64] , in-depth and focus group interviews with pwds (n = 15), caregivers (n = 15), municipality health-care staff (n = 20), general practitioners (n = 10), volunteers (n = 18) and volunteer coordinators (n = 6) will be conducted. to evaluate the acceptability and feasibility of the communication platform, interviews with caregivers and care staff will be made, as well as real-life observations form use among pwds and caregivers. table 2 presents the primary and secondary outcomes according to domain, specific measurement, metric, method of aggregation and time points. the primary outcome of the live@home.path trial is formal and informal resource utilization, measured by the rud instrument [65, 66] and the rss [67] ( table 2 ). as such, we consider overall resource utilization as more than the time required to care for the pwd; it also encompasses how burdensome the task is experienced by the caregiver. the informal care time use is measured in hours/ month [65, 68] , in addition to numbers of contacts with the health-care system and use of medications. the rud is a standardized and widely used instrument assessing dementia care, proven useful across different care systems and countries and in both clinical trials and observational studies [65, 66] . caregivers stress will be assessed by the rss, a self-report instrument covering three dimensions of "emotional distress", "social distress" and "negative feelings". it is regarded as a useful instrument to stratify careers according to the risk of psychiatric morbidity [69, 70] . the secondary outcomes presented in table 2 include measures of qol, psychiatric symptom load, adl, comorbidity and pain as well as measure of goal achievements. the qol for both the pwd and the caregiver will be measured by self-report using the quality of life in alzheimer's disease scale (qol-ad) [71] and the generic quality of life measure eq-5d-5l [72] , including the eq-5d-vas scale [73] . additionally, qol for the pwd will be assessed by proxy by the caregiver with the qol-ad [71] . psychiatric symptoms for the pwd will be proxy rated by the caregiver using the neuropsychiatric inventory questionnaire (npi-12) [74] , the cohen-mansfield agitation inventory (cmai) [75, 76] and the cornell scale for depression in dementia (csdd) [77] , fig. 2 a stepped-wedge randomized control design. the randomization in time takes place at month 0. first group (red) is in the intervention period from month 1 to 6, second group (yellow) from month 7 to 12 and third group (green) from month 13 to 18. implementation seminars will be held at months 0, 6 and 12, and midway evaluation at months 3, 9 and 15. data will be collected at baseline (month 0), after the first intervention period (month 6-7), after the second intervention period (month 12-13), after the third intervention period (month [18] [19] and at the end of the study at 24 months. b schedule of enrollment, interventions and assessments over the study period mean mean difference in score over the 6-month intervention period summarized for the three while caregiver psychiatric symptoms will be selfreported using the geriatric depression scale (gds) [78] in addition to the rss [67] . data on adl for the pwd will be proxy rated by the caregiver utilizing instrumental (i-adl) and personal (p-adl) measures [79] . data on pain will be obtained by self-report from the pwd using the mobid-2 pain scale [80] [81] [82] [83] [84] and the level of comorbidity will be evaluated by the interviewer according to the general medical health rating scale (gmrh) [85] . the clinical global impression of change scale (cgic) will be assessed after the intervention to quantify and track patient progress and treatment response [86] . in addition to the instruments presented in table 2 , other outcome measures include the number of adverse events (falls, disappearances outdoors, fire hazard), use of assistive technology (number of technical aids, cognitive intervention devices and assisted living systems), involvement of volunteers (number of participants with contact with a volunteer, number of hours spent with a volunteer), number of medications used (both regular and on demand) and participation in educational programs for the pwd and the caregiver. these outcome measures will be described as the mean change in sum of events (number devices, hours, medications, educational programs) over the intervention period compared to controls (as outlined in table 2 ). prior to inclusion and baseline data collection, a 1-day seminar will be arranged for the study personal to secure training in the use of tablets and scoring of relevant psychometric scales. a study manual has been developed to guide data collectors during their visits to secure standardized reporting. close to 24 h/day, telephone and mail support will be offered by the research team during times of data collection. researchers and municipal study personal will collect data at baseline as well as 6, 12, 18 and 24-month follow-up. the municipalities will receive 5000 nok per enrolled dyad to compensate for extra administrative work. at baseline, demographic data such as year of birth, gender, marital status, housing characteristics, education and employment will be collected, as well as data on the dementia syndrome, including the current score on the mini-mental state examination, norwegian version (mmse-nr3) [87, 88] , mean difference in score over the 6-month intervention period summarized for the three intervention groups compared to mean difference in score summarized for the control groups a mean difference in score over the follow-up period in 6-month intervals stratified by time from end of intervention b all assessment will be made by research personal or affiliated staff in the municipalities during home visits with the person with disability (pwd) and the caregiver a intervention groups: group 1 (red), t1-t2; group 2 (yellow), t2-t3; group 3 (green), t3-t4. control groups: (t1-t2 + t2-t3) (see fig. 2a ) b group 1 (red): three 6-month periods, t2-t3, t3-t4 and t4-t5. group 2 (yellow): two 6-month periods, t3-t4 and t4-t5. group 3 (green): one 6-month period, t4-t5 (see fig. 2a ) functional assessment staging test (fast) [89] and the informant questionnaire on cognitive decline in the elderly (iqcode) [90, 91] . the mmse-nr3 [88] will be assessed every 12 months during the trial. intention-to-treat analyses will be performed accounting for municipality as a random effect in mixed-effect models and the generalized estimating equation (gee) with nonlinear effect comparing the intervention groups to controls. repeated observations within persons will be accounted for with a correlation matrix. all secondary outcomes will be adjusted for multiple comparisons using the hochberg method [92] . given the potentially informative censoring due to dropout, institutionalization and death, we will jointly model the primary outcome and attrition through a shared person-specific random intercept. missing data will be handled using multiple imputations by chained equations (mice). the study was approved in may 2019 by the regional committee for medical and health research ethics, north norway (2019/385) and west norway (2017/ 1519) (the pilot), and registered at clinicaltrials.gov (nct04043364). assessment and utilization of personal data from the dyads as well as from volunteers and volunteer coordinators from nonprofit organizations are approved by the norwegian centre for research data (nsd) (ref. 514093). after verbal and written information, spoken and written informed consent was obtained in direct conversation with the caregiver and the pwd, if capable of providing consent for participation. if not, the next of kin or a legal advocate provided consent based on their determination on whether the pwd, when they were able, would have agreed to participate in the trial. compared to care as usual, we expect the live@home.-path trial to innovate the clinical pathway in dementia care, facilitating cost-effective, feasible and independent living at home through learning, innovation, volunteering and empowerment. participation in research is based on affirmative, unambiguous, informed and specific consent [93] . persons with cognitive impairment will often not be able to provide such a comprehensive consent or understand the scope and consequences of data assessment. local legislation for obtaining ethical permission in studies varies substantially between european countries [94] . in norway, the next of kin or a legal advocate can provide consent based on their determination of whether the person, when they were able, would have agreed to participate in the trial [23] . these principles for obtaining informed consent were applied in the live@home.path trial. from 2018, the european union-wide law on data protection, the general data protection regulation (gdpr), represents a significant step toward protection of participants in research [95] . in particular, article 6 protects pwds and their relatives from being coerced to consent without awareness of how their data will be used [96, 97] . when assessing sensitive data such as mental health, article 35 requires a data protection impact assessment (dpia), a formal process systematically analyzing, identifying and minimizing the data protection risks of a project. we developed a dpia (ephorte uib: 2019/5569) for the live@home.path trial in collaboration with the data protection official at the university of bergen, encouraging us to again evaluate which data to assess, as well as focus on safe data management. nonetheless, we anticipate the participation in the live@home.path trial to be less burdensome relative to, for example, rcts on effect of medications, due to the user-oriented approach emphasizing the investigation of the perspective "what matters to you?" stakeholders and research funders increasingly require patient and public involvement (ppi) at all stages of research from design, implementation and dissemination of results, shifting focus from research "about" or "for" to research "with" or "by" someone [98, 99] . our userrepresentative has provided feedback on a close to weekly basis through participation in the working group and advisory board of the trial. a related principle, responsible research and innovation (rri), is defined as a transparent, interactive process making societal actors and innovators mutually responsive to each other, and encouraging them to set up a critical perspective when evaluating the innovation and marketability of products [100, 101] . taken together, these components constitute a framework for sustainable ethic innovation in dementia research (fig. 3) , a model that easily can be applied when designing and conducting research on other vulnerable patient groups. a stepped-wedge randomized controlled trial design is recommended for evaluation of a multicomponent intervention in health-care services as it provides a number of practical and scientific benefits compared to an ordinary rct [61] . it is increasingly used in effectiveness studies in the geriatric field [102, 103] . most importantly, the design allows for providing the intervention to all participants, overcoming ethical and logistical challenges arising from withholding the intervention. this design is, however, more vulnerable to temporal external changes, as more participants are exposed to the intervention toward the end of the study than in earlier stages. if the live intervention fails to prove an effect on resource utilization, we will examine whether this is due to a lack of proper implementation. thus, if the implementation process is satisfactory, it may suggest that the live components were not tailored to be sufficiently cost-effective if no effects on primary outcome measures are found. an alternative interpretation is that the intervention may not be cost-effective even if primary outcomes change significantly, as resource use by the intervention is more time consuming and/or expensive than the alternative. some challenges have emerged during the start of the trial. first, it is demanding to include the estimated number of participants, and, additionally, to keep the number of dropouts low due to the progression of the disease. we should have established closer collaborations with the geriatric specialist health-care services, as we experienced that patients recruited from geriatric outpatient clinics were in the most optimal disease stage for this trial. to increase recruitment, we prolonged the inclusion period to 31 december 2019 and expanded the inclusion criteria to age ≥ 64 years and mmse range 15-27, while the sefas researchers, journalist and co-researcher with user experience continuously work on positive media coverage. second, data collection from home-dwelling persons in three distinct municipalities is resource and logistically demanding. third, being selected as a pilot for the data collection software has been challenging, as the file format initially generated handled missing data in a way that was not compatible with our statistical programs. finally, the participants have so far been recruited in various ways, from home-care services in the municipality and memory clinics at hospitals, to self-referrals after advertisements in the general media. this implies that the dyads included in our trial represent a heterogeneic group of home-dwelling people with dementia. in conclusion, we expect the implementation of live to lead to a pathway for dementia treatment and care that is cost-effective, feasible and supports independent living, at home. a total of 428 dyads had been screened for participation from 20 may 2019, of which 279 were included in the trial. by january 2020, when recruitment ended, 31 dyads had dropped out. mainly due to a more rapid inclusion process than anticipated, this protocol was submitted after the end of the recruitment period but in due time before the last visit for data collection. at the time of resubmission in may 2020, the covid-19 pandemic had profoundly impacted the norwegian healthcare system, including services in the municipal sector, challenging the implementation of the intervention in group 2. newsletters with status, possible modifications and upcoming events will be sent by e-mail to the site leaders and coordinators every 2-3 months. final protocol version number 5 will be prepared by 1 june 2019. plan for dissemination apart from the usual academic publications from the live trial in terms of papers and conference presentations, the authors will ensure maximum publicity through the collaborating centers' popular blogs, media work and scientific network. the latter includes most of the world's leading experts on pain, bpsd, palliative care, and wearable and sensing technology for people with dementia. we will exploit the technology network, cost-action td1005 group, and conduct research visits to three of the overseas associated centers of excellence (harvard university, yale university and tohoku university) that are part of our management group; host at least four visits by overseas members of the network; host two major 2-day international workshops (years 2 and 4); and host nine seminars for formal caregivers in homecare services. the live website will also provide a forum for outreach for the public, including research participants, continuously updated with results from the trial. researchers will attend two international conferences per year, while we expect each researcher to attend a conference every other year to achieve coverage and exposure of the trial. conception or design of the work: bsh is the principal investigator of the trial, lib is the site lead for the trial. all coauthors have contributed substantially to the conception of the idea and at the different stages of development of the trial and/or toward the different components of the intervention and/or practical conduction of the trial. drafting the article: bsh and lib drafted the manuscript. critical revision of the article: all coauthors contributed significantly to the critical revision of the drafts, improving the method and its content. final approval of the version to be published: all coauthors approved the final submitted version of the manuscript. the international committee of medical journal editors criteria for authorship will be applied to evaluate whether contributors fulfill the criteria for authorship on future publications with data from the trial. no professional writers will be involved in manuscripts with data from the trial. the trial is funded by the research council of norway (www.forskningsradet. no) (sponsor's protocol code 273581), the research council of norway (sponsor's protocol code-pre-project 261626 (uib) and 261605 (haraldsplass deaconess hospital)), including two phd positions (mv and mhg) and three postdoctoral positions (rca, np and lib). the dignity centre funds one additional phd position (eh). the sponsors will have no role in planning the design, collection, management, analysis, interpretation of data and writing of reports and will have no decision on where to submit the report for publication. data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. the public will not receive full access to the complete protocol, dataset and statistical procedures; however, this information can be made available to other researchers upon request. the study was approved in may 2019 by the regional committee for medical and health research ethics, north norway (2019/385) and west norway (2017/1519) (the pilot), and registered at clinicaltrials.gov (nct04043364). assessment and utilization of personal data on the dyads, volunteers and volunteer coordinators from nonprofit organizations are approved by the norwegian centre for research data (nds) (ref. 514093). after verbal and written information, spoken and written informed consent was obtained in direct conversation with the caregiver and the pdw, if capable of providing consent for participation. if not, the next of kin or a legal advocate provided consent based on their determination on whether the pwd, when they were able, would have agreed to participate in the trial. not applicable. the world health organization, dementia a public health priority dementia: a global health priority-highlights from an adi and world health organization report the world health organization, 10 facts on dementia heterogeneity and changes in preferences for dying at home: a systematic review we live as good a life as we can, in the situation we're in"-the significance of the home as perceived by persons with dementia the norwegian insitute of public health. public health report dementia. oslo: the norwegian institute of public health alzheimer's disease facts and figures. chichago: the alzheimers association effect of a training programme to reduce stress in carers of patients with dementia the going to stay at home program: combining dementia caregiver training and residential respite care time until institutionalization and death in patients with dementia. role of caregiver training and risk factors cost effectiveness of a training program for dementia carers caregiver burden among dementia patient caregivers: a review of the literature evidence of what works to support and sustain care at 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ministry of health and care services developing and evaluating complex interventions: the new medical research council guidance effectiveness of educational interventions for informal caregivers of individuals with dementia residing in the community: systematic review and meta-analysis of randomised controlled trials the effect of psychosocial support intervention on depression in patients with dementia and their family caregivers: an assessor-blinded randomized controlled trial the norwegian advisory unit on ageing and health. educational program for relatives a review of the role of assistive technology for people with dementia in the hours of darkness telehealth and telecare need a different approach sensing technology to facilitate behavioral and psychological symptoms and to monitor treatment responses in people with dementia. a systematic review security approaches in using tablet computers for primary data collection in clinical research volunteerism research: a review essay updated numbers on volunteering in norway satelite acount for non profit organisations the bravo team. the benefits associated with volunteering among seniors: a critical review and recommendations for future research volunteering and subjective wellbeing in midlife and older adults: the role of supportive social networks meeting needs in a welfare state: relations between government and voluntary organizations in norway the norwegian government. the voluntary sector the red cross the norwegian association for public health co-producing a shared understanding and definition of empowerment with people with dementia the national ministry of health, national guideline for diagnosis and treatment of dementia. oslo: the national ministry of health survival times in people with dementia: analysis from population based cohort study with 14 year follow-up the compound role of a coordinator for home-dwelling persons with dementia and their informal caregivers: a qualitative feasibility study of 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"rud-foca" (resource utilization in dementia-formal care) the relative stress scale, a useful instrument to identify various aspects of carer burden in dementia? high score on the relative stress scale, a marker of possible psychiatric disorder in family carers of patients with dementia use of the qol-ad for measuring quality of life in people with severe dementia-the laser-ad study utility-based quality of life measures in alzheimer's disease correspondence between eq-5d health state classifications and eq vas scores the neuropsychiatric inventory: comprehensive assessment of psychopathology in dementia factor analysis of the cohen-mansfield agitation inventory in three large samples of nursing home patients with dementia and behavioral disturbance assessment of agitation in elderly patients with dementia: correlations between informant rating and direct observation cornell scale for depression in dementia development and validation of a geriatric depression screening scale: a preliminary report aging and performance of home tasks the mobid-2 pain scale: reliability and responsiveness to pain in patients with dementia who suffers most? dementia and pain in nursing home patients: a cross-sectional study pain behaviour and pain intensity in older persons with severe dementia: reliability of the mobid pain scale by video uptake pain in older persons with severe dementia. psychometric properties of the mobilization-observation-behaviour-intensity-dementia (mobid-2) pain scale in a clinical setting mobilization-observation-behavior-intensity-dementia pain scale (mobid): development and validation of a nurse-administered pain assessment tool for use in dementia the general medical health rating: a bedside global rating of medical comorbidity in patients with dementia ecdeu assessment manual for psychopharmacology mini-mental state". a practical method for grading the cognitive state of patients for the clinician the norwegian national advisory unit on ageing and health. mmse-nr3 functional assessment staging (fast) the informant questionnaire on cognitive decline in the elderly (iqcode): a review the informant questionnaire on cognitive decline in the elderly (iqcode): socio-demographic correlates, reliability, validity and some norms controlling the false discovery rate: a practical and powerful approach to multiple testing the european union general data protection regulation (eu 2016/679) and the australian my health record scheme-a comparative study of consent to data processing provisions huge variation in obtaining ethical permission for a non-interventional observational study in europe the eu's general data protection regulation (gdpr) in a research context impossible, unknowable, accountable: dramas and dilemmas of data law why and how we should care about the general data protection regulation alzheimer europe's position on involving people with dementia in research through ppi (patient and public involvement) public involvement in health and social sciences research: a concept analysis the assisted living project: a process evaluation of implementation of sensor technology in community assisted living. a feasibility study when robots care: public deliberations on how technology and humans may support independent living for older adults nurse-led medicines' monitoring for patients with dementia in care homes: a pragmatic cohort stepped wedge cluster randomised trial alleviating staff stress in care homes for people with dementia: protocol for stepped-wedge cluster randomised trial to evaluate a web-based mindfulness-stress reduction course publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the live@home.path trial is funded by the research council of norway with two phd grants and three postdoctorate grants. the centre for elderly and nursing home medicine at the university of bergen responsible for conducting the trial is funded by gc rieber foundations and the norwegian government. the authors acknowledge valuable support from the collaborating municipalities and their main contact person anne marie hanson (baerum), beate sørensen (kristiansand) and anita krokeide (bergen), as well as from the dignity centre, the dam foundation western norway university of applied sciences and the norwegian national advisory unit on women's health, oslo university hospital. supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04414-y.additional file 1. implementation seminar for the live@home.path trial. key: cord-263628-ac9gld5l authors: sivapalan, pradeesh; ulrik, charlotte suppli; lappere, therese sophie; eklöf, josefin viktoria; shaker, saher burhan; bødtger, uffe christian steinholtz; browatzki, andrea; meyer, christian niels; weinreich, ulla møller; laursen, christian b.; biering-sørensen, tor; knop, filip krag; lundgren, jens d.; jensen, jens-ulrik stæhr title: proactive prophylaxis with azithromycin and hydroxychloroquine in hospitalized patients with covid-19 (propac-covid): a statistical analysis plan date: 2020-10-20 journal: trials doi: 10.1186/s13063-020-04795-0 sha: doc_id: 263628 cord_uid: ac9gld5l background: there is an urgent need for treatments that can shorten hospitalization and lower the risk of secondary infection and death in patients with corona disease. the propac-covid trial evaluates whether combination therapy with macrolide azithromycin and hydroxychloroquine via anti-inflammation/immune modulation, antiviral efficacy, and pre-emptive treatment of supra-infections can shorten hospitalization duration and reduce the risk of non-invasive ventilation, treatment in the intensive care unit, and death in patients with acute hospital admission and a positive test for 2019-ncov and symptoms of covid-19 disease. methods: the propac-covid is a multi-center, randomized, placebo-controlled, double-blinded clinical trial. the primary outcome is number of days spent alive and out of hospital within 14 days from randomization. randomization will be in blocks of unknown size, and the final allocation will be stratified for age, site of recruitment, and whether the patient has any chronic lung diseases. data is analyzed using intention-to-treat (itt) principles, and main analyses will also be subject to modified itt analysis and per protocol analysis. discussion: this paper describes the detailed statistical analysis plan for the evaluation of primary and secondary endpoints of the propac-covid study. enrolment of patients to the propac-covid study is still ongoing. the purpose of this paper is to provide primary publication of study results to prevent selective reporting of outcomes, data-driven analysis, and to increase transparency. trial registration: clinicaltrials.gov nct04322396. registered on 26 march 2020. in the ongoing coronavirus disease 2019 pandemic that arose in wuhan, china, there is still sparse knowledge of the course, risk of complications, and how hospitalized patients are best treated to ensure best possible survival and shortest duration of hospitalization. presently, symptomatic and organ supportive therapy, including assisted ventilation in acute hypoxic respiratory failure, is recommended [1] . a high incidence of bacterial super-infections in patients with covid-19 has been reported, and patients with more severe covid-19 seem to have a high risk of death due to septic shock [2] . the length of hospitalization is observed to be relatively long, 10-15 days [3] , which in itself is a problem as hospitals can quickly reach the maximum capacity for hospitalization and the proportion of patients who become critically ill have, on the observations reported so far, had a mortality rate of > 60% [4] , and overall mortality for admitted patients in china with covid-19 infection is apparently unusually high for viral respiratory tract infections, up to 25% [5] . thus, there is an urgent need for treatments that can improve patients' outcomes in covid-19 including lower risk of secondary infection, death and shorter duration of hospital admission. the study will clarify whether drug treatment with azithromycin in combination with hydroxychloroquine for 15 days from hospitalization with diagnosed covid-19 infection in hospitalized patients may reduce the length of hospitalization, the risk of hospitalization in the intensive care unit (icu), treatment with non-invasive ventilation (niv), and death. the study will also clarify whether this treatment can reduce the need for oxygen supplementation (time for breathing on its own without oxygen supplementation) or for regular long-term oxygen therapy oxygen supplementation ("home oxygen"). in patients with acute hospital admission, a positive test for sars-cov-2 and symptomatic covid-19 and treatment with virus-modifying drug hydroxychloroquine as well as virus-immunomodulatory and antibacterial drug azithromycin can lead to shorter hospitalization and fewer admissions to the icu. the objective of this randomized, placebo-controlled, double-blinded multi-center trial is to investigate whether 15-day treatment with azithromycin and hydroxychloroquine added to standard of care can shorten hospitalization and reduce the risk of non-invasive ventilation, admittance to icu, and death. the patients are enrolled in the trial only after obtaining informed consent. the trial is conducted at eight centers in denmark: i) intervention group: days 1-3: azithromycin 500 mg × 1 od plus hydroxychloroquine 200 mg × 2 od; days 4-15: azithromycin 250 mg × 1 od plus hydroxychloroquine 200 mg × 2 od ii) control group: the control group will receive placebo for both types of intervention medications. if the investigational therapy (or part of) becomes standard treatment during the study, this may also be offered to the control group the analyses described in this document will be performed by coordinating investigator pradeesh sivapalan, md phd (section of respiratory medicine, department of medicine, herlev-gentofte hospital, university of copenhagen, herlev and gentofte, denmark) in cooperation with the sponsor and principal investigator jens ulrik jensen, once the data have been entered, cleaned, and released for use. this document provides a detailed description of the statistical analyses that will be performed for the evaluation of the primary and secondary endpoints of protocolized for the propac-covid study [6] . the analyses described in this document are compatible with the recommendations of the consort 2010 statement [7] (fig. 1) . the international conference on harmonisation (ich) of good clinical practice (gcp) [1] and leading experts recommend that randomized clinical trials should be analyzed according to predefined outcomes and a predefined statistical analysis plan [2] . to prevent selective reporting of outcomes and data-driven analysis and to increase transparency, this paper describing the detailed statistical analysis plan for the propac-covid trial will be published while enrolment of patients and collection of data is still ongoing and before the database is accessed for trial results. randomization will be in blocks of unknown size and the final allocation will be stratified for age (> 70 vs. ≤ 70 years), site of recruitment, and whether the patient has any of the following chronic lung diseases (yes vs. no): chronic obstructive pulmonary disease, asthma, bronchiectasis, and interstitial lung disease. data will be analyzed using intention-to-treat (itt) principles and main analyses will also be subject to modified itt analysis (started but not completed the study) and per protocol analysis (completed all interventions). when applying the itt principle, all randomized patients will be analyzed in the groups to which they were originally allocated, regardless of whether they received the intended treatment or whether a protocol violation or protocol deviation occurred. patients who withdraw consent for the use of their data will not be included in any analysis; only the study group originally randomized to and withdrawal of consent will be reported. a secondary analysis of the primary efficacy outcome will use a per protocol (pp) population. a consort diagram of participants will be presented in the study. the power to avoid a type ii error is 80% (1-β) at a twosided 5% significance level, using a t test for the primary outcome, and a group-sequential design allowing for one interim analysis at half target recruitment. this led to a sample size of 226 subjects. all confidence intervals (cis) reported will be 95% cis. full details of the sample size calculation are described in the protocol article. all analyses will be performed using sas software version 9.4. planned analyses of safety and efficacy data (interim analysis) will be evaluated when 113 patients have completed the study (completed 1-month follow-up). these assessments will be made by an independent data and safety monitoring board (dsmb). the interim analysis will focus on reporting the following: selected baseline data (those readily available from the baseline data list below), primary outcome (in an o' brien-fleming plot), and all-cause mortality at 30 days (chi-square or fisher's exact test, whichever appropriate). to adjust the type 1 error rate for multiplicity, we will use the o'brien-fleming method in a group-sequential design, resulting in an alpha level for the interim analysis at 0.0054 and for the final analysis at 0.0492. the dsmb will review the protocol and monitoring guideline, evaluate the attempts to recruit participants and participants' risk, and, on the basis of interim analyses, make recommendations to investigators as to whether to continue the study. in addition, the dsmb may at any time require an extraordinary interim analysis. descriptive analyses-baseline characteristics at study enrolment (defined as day 1) the following baseline characteristics of the study population will be summarized separately within each randomized group: age, median (interquartile ranges (iqr)), years male sex, n (%) ethnicity (caucasian, african (incl. african-american), asian, inuit, unknown/other) body mass index (kg/m 2 , median, iqr) current smoker, n (%) ex-smoker, n (%) non-smoker, n (%) pack-years history (median, iqr, years) use of oxygen therapy, n (%) use of continuous positive airway pressure, n (%) use of non-invasive mechanical ventilation (niv), n (%) infiltrates on chest x-ray, n (%) oxygen consumption: l/min (median, iqr) oxygen consumption: fraction of inspired oxygen (fio 2 (median, iqr)) clinical findings (daily measurements) the percentage of patients followed for each outcome data parameter will be reported for all predefined outcomes (primary and all secondary). exploratory outcome analyses will be planned by the study group on suggestion form the reviewers/editors etc. percentage with followed/ missing data will also be reported for these outcomes. type of antibiotics (non-study drugs) ciprofloxacin, piperacillin/tazobactam, ceftazidime, meropenem, colistin, gentamycin, amoxicillin, amoxicillin/clavulanic acid, roxithromycin, dicloxacillin, penicillin, azithromycin, or others days with antibiotics-any (median days on any type) days with corticosteroids (median days) for continuous variables, means and standard deviations will be presented, when normally distributed, otherwise as medians and iqr. for categorical variables, the number and percentage of participants within each category will be presented. for each variable, the percent of missing values will be reported. for categorical values, chi-square and fisher's exact test will be used. for time-to-event variables, cox regression and log-rank test will be used, and for the latter, a corresponding kaplan-meier plot will be presented. the primary outcome is a continuous outcome: "days alive and out of hospital within 14 days (daoh14) after recruitment." the outcomes are defined as number of days spent alive and out of hospital within 14 days from randomization. this is sensitive outcome used in previous publications [8, 9] . among other advantages, leadtime bias due to death was avoided using this endpoint measure (i.e., patients who died early would not be counted as a short length of stay). data for the primary outcome will be analyzed using a general linear model adjusted for the stratification covariates (age, site, and chronic lung disease) and estimated means and difference in means with 95% ci will be presented. additionally, for sensitivity analysis median with iqr with corresponding non-parametric test, e.g., mann-whitney u test will be presented. in the case of missing covariate data, multiple imputations will be used. the estimation from the study group is that daoh14 will be a number above or equal to 4. if daoh14 is < 4, daoh at 21 days will be presented instead. apart from the main analysis, the primary outcome analysis will be performed as an adjusted analysis using general linear models while adjusting for the following variables: age (per year increase), sex (m/f), copd gold c/d (yes vs. no), heart failure nyha iii-iv (yes vs. no), and current smoker (yes vs. no). the patient will be categorized into one of the following 8 categories depending on status of their hospitalization. only one category can be "yes": for this analysis, the patient will be assigned a number between 1 and 8. frequencies for the categories will be presented. a proportional odds logistic regression model will be applied. the key parameter of interest is the "common odds ratio," which quantifies the shift in the severity distribution resulting from treatment. for an efficacious treatment, an odds ratio greater than 1 quantifies an improvement in disease severity; a value of 2 indicates a bigger improvement than a value of 1.25. if the preconditions for the proportional odds model are not considered fulfilled, we will present the frequencies and calculate p values for shifts in levels by a wilcoxon rank-sum test. number of patients admitted to intensive care will be compared using chi-square test. length of stay in icu will be analyzed using a t test. days not alive within the time frame will be added to days at icu. if days not alive are equal in the two treatment groups, we will further present days at icu excluding days not alive. use of niv will be compared by a chi-square test. differences in mortality will be calculated using cox proportional hazards adjusting for the following variables: age (per year increase), sex (m/f), copd gold c/d (yes vs. no), heart failure nyha iii-iv (yes vs. no), and active smoker (yes vs. no). treatment effects will be presented as hazard ratios (hr) and 95% cis. furthermore, kaplan-meier plot will be presented in combination with the log-rank test. patients will be censored in the case of lost to follow-up. length of hospitalization between groups will be compared using a t test. this is equal to the primary endpoint but with a longer time frame and will be analyzed similarly. differences in mortality will be calculated using cox proportional hazards adjusting for the following variables: age (per year increase), sex (m/f), copd gold c/d (yes vs. no), heart failure nyha iii-iv (yes vs. no), and active smoker (yes vs. no). treatment effects will be presented as hazard ratios (hrs) and 95% cis. furthermore, kaplan-meier plot will be presented in combination with the log-rank test. patients will be censored in the case of lost to follow-up. however, this is not expected, since follow-up for these values is 100.0% in the danish health registry. differences in mortality will be estimated using both unadjusted and adjusted analyses. for the adjusted analysis, a cox proportional hazards model will be used and adjustment for the following variables will be done: age (per year increase), sex (m/f), copd gold c/d (yes vs. no), heart failure nyha iii-iv (yes vs. no), and active smoker (yes vs. no). treatment effects will be presented as hrs and 95% cis. furthermore, kaplan-meier plot will be presented in combination with the log-rank test. patients will be censored in the case of lost to follow-up. 9. time to readmission (all causes) [time frame: 30 days] 10. differences in readmission will be calculated using cox proportional hazards adjusting for the following variables: age (per year increase), sex (m/f), copd gold c/d (yes vs. no), heart failure nyha iii-iv (yes vs. no), and active smoker (yes vs. no). treatment effects will be presented as hrs and 95% cis. furthermore, kaplan-meier plot will be presented in combination with the log-rank test. patients will be censored in the case of lost to follow-up. delta paco 2 measured in arterial blood gas analysis. changes will be calculated by an ancova method adjusting for baseline values. ph measured in arterial blood gas analysis. levels in ph will be compared using a t test. 14. time to no oxygen supplement (or regular oxygen supplement "long-term oxygen therapy") [time frame: 14 days] time to no oxygen supplement will be presented by the kaplan-meier method and differences calculated by log-rank test. for all analyses using parametric statistics (t test, ancova), the distribution will be inspected. biochemical markers will be transformed if necessary whereas length of stays will not be transformed. if parametric statistics is considered inappropriate, a non-parametric -ecg: qtc: n (%) patients in both arms who at any time point after baseline had a qtc (f) > 500 ms. we will do separate analysis for men and women. -n (%) ventricular arrhythmias (apart from ventricular extrasystoles and non-sustained ventricular tachycardia) scheduled to perform the following stratified analyses for the primary outcome: -stratified analyzes in the presence of chronic lung disease or not -stratified analyzes for qtc across the median -stratified analyzes for < 2 l/min nasal oxygen vs. ≥ 2 l nasal oxygen -stratified analyzes crp < 50 mg/l and crp ≥ 50 mg/l -stratified analyzes d-dimer > 0.8 mg/l or d-dimer ≥ 0.8 mg/l -stratified for remdesivir treatment (yes or no) the first figure will be a consolidated standards of reporting of randomized trials (consort) flow chart. the second figure will be a kaplan-meier plot to describe the rate of death by treatment arms. the third figure will be a forest plot illustrating all the preplanned sub analyses. the first table will be the baseline characteristics of the itt population ( table 1 ). the second table will include the primary and secondary outcomes according to the two allocation and pairwise comparisons. the detailed analysis plan was written in strict concordance with the trial protocol approved by the regulatory authorities prior to recruitment initiation. the entire statistical analysis plan was published at www.coptrin.dk before the trial was finalized (before the database was closed). all analyses will be done prior to breaking of the randomization code (analysis comparisons between "arm a" and "arm b" (random names). the coordinating investigator (ps) and the study sponsor and principal investigator (juj) will conjointly perform all the data analyses according to this plan, except the interim analyses which will be performed by dr. josefin eklöf (who is not an investigator of this trial) from section of respiratory medicine, department of medicine, gentofte hospital, university of copenhagen, hellerup, denmark. an unblinding date will be chosen and published online at www.coptrin.dk, and on this date, the allocation will be unblinded. after unblinding of the allocation, further analysis will not be done, except on request from reviewers/editors handling submitted papers. care for critically ill patients with covid-19 critically ill patients with the middle east respiratory syndrome: a multicenter retrospective cohort study clinical characteristics of refractory covid-19 pneumonia in wuhan, china clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study proactive prophylaxis with azithromycin and hydroxychloroquine in hospitalised patients with covid-19 (propac-covid): a structured summary of a study protocol for a randomised controlled trial explanation and elaboration: updated guidelines for reporting parallel group randomised trials eosinophil-guided corticosteroid therapy in patients admitted to hospital with copd exacerbation (cortico-cop): a multicentre, randomised, controlled, open-label, non-inferiority trial days alive and out of hospital and the patient journey in patients with heart failure: insights from the candesartan in heart failure: assessment of reduction in mortality and morbidity (charm) program publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the steering committee of cop:trin for input and advice during the trial recruitment.authors' contributions ps drafted the manuscript for this paper in close collaboration with csu, tsl, je, sbs, usb, ab, cnm, umw, cbl, tbs, fkk, jdl, and juj. all authors made substantial contributions to the process of developing the manuscript and contributed with scientific input. all authors read and approved the final manuscript. juj is the sponsor and principal investigator, and ps is the coordinating investigator. the trial was funded by the novo nordisk foundation (grant number: nnf20sa0062834) with dkk 2,200,000. the research salary of ps was sponsored by herlev and gentofte hospital, university of copenhagen. the trial is not supported in any way by the pharmaceutical industry. the funding sources have not had or will have any influence on trial design, data collection, analysis, or reporting. information regarding subjects is processed and stored in accordance with the data protection regulation (gdpr), the data protection act, and the health act, and the project is properly notified in accordance with applicable rules and laws to the appropriate authorities. the propac-covid trial was approved by research ethics committees of all participating sites (h-20022574), the danish medicines agency (eudract no: 2020-001198-55), and the danish data protection agency (2020-256). written and oral information on the trial is given to all patients considered for the trial, and patients will only be enrolled in the trial after signing a statement of consent. not applicable. the authors declare that they have no competing interests. these blood tests will also be recommended daily for covid patients outside studies in the recommendation of the danish lung medicine association **when screening for the study, any ecg from within the last 3 days can be used ***a follow-up ecg can be recorded during any remaining days of the hospital admission ****only in patients with copd key: cord-255101-l5ssz750 authors: daval, mary; corré, alain; palpacuer, clement; housset, juliette; poillon, guillaume; eliezer, michael; verillaud, benjamin; slama, dorsaf; ayache, denis; herman, philippe; jourdaine, clement; hervé, camille; el bakkouri, wissame; salmon, dominique; hautefort, charlotte title: efficacy of local budesonide therapy in the management of persistent hyposmia in covid-19 patients without signs of severity: a structured summary of a study protocol for a randomised controlled trial date: 2020-07-20 journal: trials doi: 10.1186/s13063-020-04585-8 sha: doc_id: 255101 cord_uid: l5ssz750 objectives: to assess the efficacy of local intranasal treatment with budesonide (nasal irrigation), in addition to olfactory rehabilitation, in the management of loss of smell in covid-19 patients without signs of severity and with persistent hyposmia 30 days after the onset of symptoms. to search for an association between the presence of an obstruction on mri and the severity of olfactory loss, at inclusion and after 30 days of treatment. trial design: two center, open-label, 2-arm (1:1 ratio) parallel group randomized controlled superiority trial. participants: inclusion criteria patient over 18 years of age; patient with a suspected sars-cov-2 infection, whether or not confirmed by pcr, or close contact with a pcr-confirmed case, typical chest ct scan (unsystematic frosted glass patches with predominantly sub-pleural appearance, and at a later stage, alveolar condensation without excavation or nodules or masses) or positive serology ; patient with isolated sudden onset hyposmia persisting 30 days after the onset of symptoms of cov-2 sars infection; affiliate or beneficiary of a social security scheme; written consent to participate in the study. non-inclusion criteria known hypersensitivity to budesonide or any of the excipients; hemostasis disorder or epistaxis; oral-nasal and ophthalmic herpes virus infection; long-term corticosteroid treatment; treatment with potent cyp3a4 inhibitors (e.g., ketoconazole, itraconazole, voriconazole, posaconazole, clarithromycin, telithromycin, nefazodone and hiv protease inhibitors); severe forms of sars-cov-2 with respiratory or other signs; hyposmia persisting for more than 90 days after the onset of symptoms other causes of hyposmia found on interrogation or mri; patient benefiting from a legal protection measure; pregnant or breastfeeding women. the participants will be recruited from: hôpital fondation adolphe de rothschild and hôpital lariboisière in paris, france intervention and comparator: intervention: experimental group: nasal irrigation with budesonide and physiological saline (budesonide 1mg/2ml diluted in 250ml of physiological saline 9°/00): 3 syringes of 20ml in each nasal cavity, morning and evening, for 30 days, in addition to olfactory rehabilitation twice a day. control group: nasal irrigation with physiological saline 9°/00 only: 3 syringes of 20cc in each nasal cavity, morning and evening, for 30 days, in addition to olfactory rehabilitation twice a day. main outcomes: percentage of patients with an improvement of more than 2 points on the odoratest score after 30 days of treatment. randomisation: patients will be randomized (1:1) between the experimental and control groups, using the e-crf. the randomization list will be stratified by centre. blinding (masking): participants and caregivers are aware of the group assignment. people assessing the outcomes are blinded to the group assignment numbers to be randomised (sample size) 120 patients are planned to be randomized into two groups of 60 patients. trial status: mdl_2020_10. version number 2, may 22, 2020. recruitment started on may 22, 2020. the trial will finish recruiting by august 2020. trial registration: eudract number: 2020-001667-85; date of trial registration: 15 may 2020 protocol registered on clinicaltrial.gov, registration number: nct04361474; date of trial registration: 24 april 2020. full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. essai randomisé contrôlé évaluant l'efficacité d'un traitement local par budésonide dans la prise en charge de l'hyposmie chez les patients covid-19 sans signes de gravité. acronyme covidorl hôpital fondation adolphe de rothschild 29 rue manin 75019 paris dr mary daval service d'orl hôpital fondation adolphe de rothschild nombre de centres 2 les symptômes initiaux décrits chez les premiers cas de covid-19 étaient essentiellement la fièvre et les signes respiratoires. récemment, des médecins ont constaté dans plusieurs pays (1) une augmentation des cas de perte de l'odorat, sans obstruction nasale ni rhinorrhée associée. même si nous ne connaissons pas encore les conséquences au long cours du covid-19 sur les capacités olfactives, il existe des données de la littérature confirmant que les hyposmies post-virales sont une source importante de troubles olfactifs sur le long terme, impactant la qualité de vie (2) . habituellement, le traitement des hyposmies virales repose sur un traitement corticoïde par voie locale et/ou générale associé à des lavages de nez au sérum physiologique dès l'apparition des signes. la société française d'orl a, du fait de la possible gravité de l'atteinte virale à sars-cov-2, déconseillé le traitement par corticothérapie ainsi que les lavages de nez associés à une rééducation olfactive. cependant, le virus étant en moyenne présent dans les fosses nasales pendant 20 jours (3), une hyposmie persistante à 30 jours serait probablement due à une atteinte inflammatoire ou neurologique des fentes ou bulbe olfactif (objectivée ou non par l'irm). un traitement local par corticoïdes pourrait être instauré à partir de 30 jours du début des symptômes de covid-19 sans risque de dissémination. dans les hyposmies persistantes hors rhinosinusites chroniques, le seul traitement (4) ayant prouvé son efficacité comporte des lavages de nez associés au budésonide et à une rééducation olfactive (5) . ce médicament n'a toutefois pas l'amm en france dans cette indication. un essai thérapeutique testant un traitement associant des lavages de nez comportant du budésonide à une rééducation olfactive chez les patients présentant une hyposmie persistante à 30 jours du début des signes d'infection à sars-cov-2 parait justifié. l'analyse des irm pré et post thérapeutiques permettrait d'étudier également une éventuelle association entre une atteinte inflammatoire ou neurologique de l'organe de l'olfaction et la sévérité de la perte d'odorat. objectif principal: evaluer l'efficacité du budésonide en traitement local intranasal (lavage de nez), en complément de la rééducation olfactive, dans la prise en charge de la perte d'odorat de patients covid-19 sans signes de gravité et présentant une persistance de l'hyposmie 30 jours après le début des symptômes. critère de jugement principal: pourcentage de patients ayant une amélioration de plus de 2 points sur le score odoratest (5) après 30 jours de traitement. du début des signes de l'infection à sars-cov-2 ; -absence de portage sars-cov-2 confirmée par pcr au moment de l'inclusion -affilié ou bénéficiaire d'un régime de sécurité sociale ; -consentement écrit de participation à l'étude. critères de non inclusion: -hypersensibilité connue au budésonide ou à un des excipients du médicament ; -trouble de l'hémostase, ou épistaxis ; -infection oro-bucco-nasale et ophtalmique par herpès virus ; -traitement par corticoïdes au long cours ; -traitement par inhibiteurs puissants du cyp3a4 (ex : kétoconazole, itraconazole, voriconazole, posaconazole, clarithromycine, télithromycine, néfazodone et inhibiteurs des protéases du vih) ; -formes de sars-cov-2 avec signes respiratoires ou autres que l'anosmie persistant à 30 jours du début des symptômes ; -hyposmie persistante depuis plus de 90 jours après le début des symptômes ; -autres causes d'hyposmie mises en évidence à l'interrogatoire ou à l'irm ; -patient bénéficiant d'une mesure de protection juridique ; -femme enceinte ou allaitante. symptômes évocateurs d'une symptomatologie marquant une reprise de l'activité virale lors de l'appel téléphonique à j8.  screening : les patients présentant une hyposmie brutale isolée persistant entre 30 et 90 jours après le début des symptômes d'une infection à sars-cov-2 suspectée par le tableau clinique et/ou confirmée par pcr sur écouvillon nasal ou ecbc, scanner thoracique ou sérologie seront contactés par téléphone afin de leur proposer de participer à l'étude et de vérifier les critères d'éligibilité. si les patients sont intéressés, la note d'information leur sera envoyée par mail et une prescription pour réaliser une pcr en ville. une consultation physique dans un des deux centres inclueurs (hôpital fondation adolphe de rothschild, hôpital lariboisière) sera programmée entre j30 et j90 après le début des premiers symptômes d'infection à sars-cov-2.  inclusion (j-1): au cours de la consultation, le médecin investigateur recueillera le consentement de participation à l'étude. si le patient répond « non » à la question « avez-vous totalement récupéré les capacités olfactives que vous aviez avant le début de l'apparition des symptômes de covid-19 », il pourra être inclus dans l'étude. un test olfactif sera réalisé. il s'agit du test de perception et d'identification odoratest (5) de cinq odorants (rose, gâteau, fromage, abricot, fèces). un questionnaire d'auto-évaluation des capacités olfactives et gustatives sera également réalisé. un examen irm 3t sera réalisé le même jour afin d'évaluer la présence de signes inflammatoires ou neurologiques. il inclura en première intention des séquences non injectées couvrant l'encéphale (3d flair, axiale diffusion, swi) et les cavités naso-sinusiennes (axial et coronal 2d t2 et/ou 3d t2 hr). une injection de produit de contraste pourra être requise secondairement, en cas de découverte d'une masse tumorale (méningiome olfactif, esthésioneuroblastome, tumeur sinusienne par exemple). après inclusion, les patients seront randomisés (1:1) entre le groupe expérimental et le groupe contrôle, à partir de l'e-crf (clinfile©). la liste de randomisation sera stratifiée sur le centre. les patients se verront remettre les traitements à l'essai et auront pour instruction de démarrer le traitement à partir du lendemain matin. groupe expérimental : traitement par budésonide local intranasal mélangé à du sérum physiologique (budésonide 1mg/2ml dilué dans 250ml de sérum physiologique 9°/00) en lavage de nez, 3 seringues de 20cc dans chaque fosse nasale matin et soir pendant 30 jours en complément de la rééducation olfactive deux fois par jour. pour les patients ayant récupéré totalement (réponse de type oui/non à la question « avez-vous totalement récupéré les capacités olfactives que vous aviez avant le début de l'apparition des symptômes de covid-19 ? ») dans les deux groupes, le traitement par lavage de nez sera stoppé, mais il leur sera demandé de poursuivre la rééducation olfactive, deux fois par jour, jusqu'à la troisième visite de suivi. pour les patients du groupe expérimental n'ayant pas totalement récupéré, le traitement par budésonide en lavage de nez en complément de la rééducation olfactive sera poursuivi pendant 30 jours supplémentaires. pour les patients du groupe contrôle n'ayant pas totalement récupéré, le traitement par budésonide en lavage de nez sera instauré, en complément de la rééducation olfactive pendant 30 jours. les patients seront revus à j60 (jusqu'à j70). le test olfactif sera réalisé et la survenue d'événements indésirables sera recueillie dans l'e-crf. au cours de cette consultation sera également réalisé le questionnaire d'auto-évaluation des capacités olfactives et gustatives. a la suite de cette visite, la prise en charge des patients se fera selon les modalités habituelles du médecin qui les suit. une consultation téléphonique sera réalisée à 8 mois (± 2 semaines) après l'inclusion des patients. au cours de cette consultation sera réalisé le questionnaire d'auto-évaluation des capacités olfactives et gustatives. la participation des patients prendra fin à l'issue de cette consultation. nous faisons l'hypothèse que le pourcentage de patients présentant une amélioration olfactive dans le groupe contrôle sera d'environ 50% après 30 jours. afin de mettre en évidence une différence de 25% entre les deux bras (50% versus 75% de patients présentant une amélioration olfactive dans le bras traité par budésonide), environ 60 patients par bras sont nécessaires, soit un total de 120 participants (formulation bilatérale, puissance=0,8, alpha=0,05). l'analyse du critère de jugement principal sera réalisée à l'aide d'un modèle de régression logistique, ajusté sur le centre. les symptômes initiaux décrits chez les premiers cas de covid-19 étaient essentiellement la fièvre et les signes respiratoires (1) . récemment, les médecins ont constaté, en france mais également dans d'autres pays (2), une augmentation importante des cas de perte d'odorat, sans obstruction nasale ni rhinorrhée associée. une étude en cours de publication réalisée en france sur des patients présentant des symptômes de covid-19 sans signe de gravité ainsi qu'une perte de l'odorat a montré que les tests réalisés chez ces patients confirmaient dans la quasi-totalité des cas l'infection à coronavirus sars-cov-2 (in press). trois mécanismes pourraient expliquer cette perte d'odorat : (i) une atteinte neurotrope, avec atteinte élective des nerfs olfactifs et des bulbes (3) ; (ii) une atteinte muqueuse inflammatoire de la région de la fente olfactive, sans atteinte nerveuse ; (iii) une combinaison des deux. même si nous ne connaissons pas encore les conséquences au long cours du covid-19 sur les capacités olfactives, il existe des données de la littérature confirmant que les hyposmies post virales sont une source importante de troubles olfactifs au long cours impactant la qualité de vie (4). habituellement, le traitement des hyposmies virales repose sur un traitement corticoïde par voie locale et/ou générale associé à des lavages de nez au sérum physiologique dès l'apparition des signes. la société française d'orl a, du fait de la possible gravité de l'atteinte virale, déconseillé le traitement par corticothérapie ainsi que les lavages de nez (2) associés à une rééducation olfactive. en effet, le virus sars-cov-2 pourrait rester présent dans la muqueuse des fosses nasales pendant 12 (5) à 20 jours (6) en moyenne avec un maxima à 38 jours dans les formes sévères (5), et présent jusqu'au décès dans les formes létales (6) . il ne nous paraît donc pas raisonnable de traiter par corticoïdes, même locaux, des patients encore porteurs du virus (risque potentiel de contamination pulmonaire ou de blocage de la réaction inflammatoire permettant de lutter contre la dissémination, risque de contamination de l'entourage). un traitement instauré chez des patients ayant développé des symptômes de covid-19 sans signes de gravité, et présentant une hyposmie persistante 30 jours après le début des symptômes parait en revanche envisageable, sans risque de dissémination. une récente méta-analyse (7) sur le traitement des troubles de l'olfaction hors rhinosinusite chronique ne retrouve pas d'étude à fort niveau de preuve en faveur de l'efficacité des corticoïdes par voie générale ou local en spray. une seule étude de haut niveau de preuve a montré un intérêt des lavages de nez associé au budésonide (8) (7) . cette molécule, qui n'a pas l'amm en france dans cette indication, serait efficace à distance de l'apparition de l'hyposmie. un essai thérapeutique testant un traitement associant des lavages de nez comportant du budésonide à une rééducation olfactive chez les patients présentant une hyposmie persistante à 30 jours du début des signes d'infection à sars-cov-2 parait justifié. l'olfaction sera évaluée avant et après traitement grâce à des tests validés au niveau national et facilement reproductibles. le test le plus couramment employé dans la littérature internationale est le test upsit (9) qui ne fait pas appel à des concentrations différentes d'odorants, qui n'a jamais donné lieu à une validation en france et qui est produit aux etats-unis. dans le contexte de pandémie limitant les échanges postaux avec l'internationale et devant la nécessité de débuter l'étude rapidement, nous privilégierons un test facilement réalisable, reproductible et fiable, déjà validé dans une publication internationale, appelé odoratest (10). l'analyse des irm pré et post thérapeutiques permettrait d'étudier également une éventuelle association entre une atteinte inflammatoire ou neurologique de l'organe de l'olfaction et la sévérité de la perte d'odorat. le virus sars-cov-2 entraîne des hyposmies pour laquelle la communauté scientifique française et internationale ne recommande pas le traitement habituel (corticoïdes quelle que soit la voie d'administration). le virus étant en moyenne présent dans les fosses nasales pendant 20 jours, un traitement local par corticoïdes pourrait être instauré à partir de 30 jours du début des signes de covid-19, sans risque de dissémination. le seul traitement qui a prouvé son efficacité dans les hyposmies persistantes est la rééducation olfactive associée au budésonide, qui n'a pas l'amm en france dans cette indication. l'objectif de cet essai randomisé contrôlé, bicentrique, est d'évaluer l'efficacité du budésonide en traitement local intranasal (lavage de nez), en complément de la rééducation olfactive, dans la prise en charge de la perte d'odorat de patients covid-19 sans signes de gravité et présentant une persistance de l'hyposmie 30 jours après le début des symptômes. evaluer l'efficacité du budésonide en traitement local intranasal (lavage de nez), en complément de la rééducation olfactive, dans la prise en charge de la perte d'odorat de patients covid-19 sans signes de gravité et présentant une persistance de l'hyposmie 30 jours après le début des symptômes. chez les patients ayant totalement récupéré (réponse de type oui/non à la question « avez-vous totalement récupéré les capacités olfactives que vous aviez avant le début de l'apparition des symptômes de covid-19 ? ») après 30 jours de traitement, évaluer la persistance de la récupération olfactive 1 mois après l'arrêt du traitement. dans le groupe traité par budésonide, chez les patients covid-19 n'ayant pas totalement récupéré après 30 jours de traitement, évaluer l'intérêt d'une poursuite du budésonide pendant 30 jours supplémentaires. dans le groupe contrôle, chez les patients covid-19 n'ayant pas totalement récupéré après 30 jours de traitement, évaluer l'intérêt de la mise en place d'un traitement par budésonide pendant 30 jours. rechercher une association entre la présence d'une obstruction à l'irm et la sévérité de la perte olfactive, lors de l'inclusion et après 30 jours de traitement. evaluer la tolérance du budénoside. 6-décrire les capacités olfactives et gustatives des patients à l'aide d'un questionnaire d'autoévaluation. comparer au bout de 30 jours de traitement les capacités olfactives entre les deux bras 8-comparer au bout de 30 jours de traitement les capacités olfactives de type « détection des odeurs » entre les deux bras 9-comparer au bout de 30 jours de traitement les capacités olfactives de type « identification des odeurs » entre les deux bras 3 critères de jugement pourcentage de patients ayant une amélioration de plus de 2 points sur le score odoratest (10) après 30 jours de traitement (cf. annexe 1). pourcentage de patients ayant une amélioration de plus de 2 points au score odoratest 30 jours après la fin du traitement (i.e. 60 jours après la randomisation). pourcentage de patients ayant une amélioration de plus de 2 points au score odoratest après 60 jours de traitement par budésonide. pourcentage de patients ayant une amélioration de plus de 2 points au score odoratest 30 jours après l'initiation d'un traitement par budésonide (i.e. 60 jours après la randomisation). présence d'un comblement inflammatoire de la fente olfactive à l'irm ou présence d'une atteinte neurologique au niveau du bulbe olfactif. description des évènements indésirables et événements indésirables graves. -patient âgé de plus de 18 ans ; -patient avec une infection à sars-cov-2 suspectée dans un contexte épidémique, confirmée ou non par pcr, ou contact proche d'un cas confirmé par pcr, scanner thoracique typique (plages de verre dépoli non systématisées à prédominance sous-pleurale, et à un stade plus tardif de condensation alvéolaire sans excavations ni nodules ni masses) ou sérologie positive ; -absence de portage sars-cov-2 confirmée par pcr au moment de l'inclusion -patient présentant une hyposmie brutale isolée persistant à j30 du début des signes de l'infection à sars-cov-2 ; -affilié ou bénéficiaire d'un régime de sécurité sociale ; -consentement écrit de participation à l'étude. -hypersensibilité connue au budésonide ou à un des excipients du médicament ; -trouble de l'hémostase, ou épistaxis ; -infection oro-bucco-nasale et ophtalmique par herpès virus ; -traitement par corticoïdes au long cours ; -traitement par inhibiteurs puissants du cyp3a4 (ex : kétoconazole, itraconazole, voriconazole, posaconazole, clarithromycine, télithromycine, néfazodone et inhibiteurs des protéases du vih) ; -contre -indication à la réalisation d'une irm ; -formes de sars-cov-2 avec signes respiratoires ou autres que l'anosmie persistant à 30 jours du début des symptômes ; -hyposmie persistante depuis plus de 90 jours après le début des symptômes ; -patient bénéficiant d'une mesure de protection juridique ; -femme enceinte ou allaitante. -symptômes évocateurs d'une symptomatologie marquant une reprise de l'activité virale lors de l'appel téléphonique à j8. essai randomisé contrôlé, en ouvert, multicentrique. si les patients sont intéressés, la note d'information leur sera envoyée par mail et une prescription pour la réalisation d'une pcr en ville. une consultation physique dans un des deux centres investigateurs (hôpital fondation adolphe de rothschild ou hôpital lariboisière) sera programmée entre j30 et j60 après le début des premiers symptômes d'infection à sars-cov-2.  inclusion (j-1): au cours de la consultation, le médecin investigateur recueillera le consentement écrit de participation à l'étude. si le patient répond « non » à la question « avez-vous totalement récupéré les capacités olfactives que vous aviez avant le début de l'apparition des symptômes de covid-19 », il pourra être inclus dans l'étude. dans le cahier d'observation (crf) seront recueillies les données suivantes : -age, sexe, poids, taille, imc, profession -consommation tabagique, immunosuppression, hta, allergie, diabète -autres antécédents médicaux -antécédents orl -contact cas confirmé -date de début des 1ers signes -date de début de l'anosmie -apparition isolée, concomitante ou après les autres signes -description de l'anosmie : partielle, totale, parosmies, phantosmies, -autres symptômes rhinologiques -troubles du gout -autres signes de covid-19 : fièvre, frissons, toux, céphalée, myalgies, diarrhée, dyspnée, conjonctivite, laryngite -traitement reçu pour l'anosmie -traitement reçu pour le covid-19 2) . un examen irm de contrôle sera réalisé, selon les mêmes modalités que celui réalisé lors de l'inclusion. pour les patients ayant récupéré totalement (réponse de type oui/non à la question « avez-vous totalement récupéré les capacités olfactives que vous aviez avant le début de l'apparition des symptômes de covid-19 ? ») dans les deux groupes, le traitement par lavage de nez sera stoppé, mais il leur sera demandé de poursuivre la rééducation olfactive, deux fois par jour, jusqu'à la seconde visite de suivi. pour les patients du groupe expérimental n'ayant pas totalement récupéré, le traitement par budésonide en lavage de nez en complément de la rééducation olfactive sera poursuivi pendant 30 jours supplémentaires. pour les patients du groupe contrôle n'ayant pas totalement récupéré, le traitement par budésonide en lavage de nez sera instauré, en complément de la rééducation olfactive pendant 30 jours. les patients seront revus à j60 (jusqu'à j70). le test olfactif sera réalisé et la survenue d'événements indésirables sera recueillie dans l'e-crf. le questionnaire d'auto-évaluation des capacités olfactives et gustatives sera également réalisé (cf. annexe 2). a la suite de cette visite, la prise en charge des patients se fera selon les modalités habituelles du médecin suivant le patient. la participation des patients prendra fin à l'issue de cette consultation téléphonique. le patient pourra retirer son consentement et demander à sortir de l'étude à n'importe quel moment et quelle qu'en soit la raison. les données recueillies au cours de sa participation à l'étude seront conservées à moins que le patient ne s'y oppose. l'investigateur pourra interrompre temporairement ou définitivement la participation d'un patient à l'étude pour toute raison qui servirait au mieux les intérêts du patient en particulier en cas d'événements indésirables. la reprise de symptômes de covid-19 mentionnés lors de l'appel téléphonique de suivi à j8 ou à n'importe quel autre moment de l'étude, conduiront à un arrêt du traitement mais au maintien de la surveillance liée à l'étude. ils devront être rapportés sans délai au promoteur (cf 7.2.3). en cas de sortie prématurée, l'investigateur devra en documenter les raisons de façon aussi complète que possible. en cas de patient perdu de vue, l'investigateur mettra tout en oeuvre pour reprendre contact avec la personne afin de connaître les raisons de sa sortie d'essai et son état de santé. le cahier d'observation devra être rempli jusqu'à la dernière visite effectuée. la sortie d'étude d'un patient ne changera en rien la prise en charge habituelle par rapport à sa maladie.  participation à une autre recherche simultanément ou à la fin de celle-ci les patients pourront participer à d'autres études si l'investigateur considère que celles-ci n'interfèrent pas avec la présente recherche. aucune période d'exclusion n'est prévue au-delà du suivi.  arrêt définitif ou temporaire de la recherche l'étude pourra être suspendue ou interrompue en cas de survenue d'événements indésirables nécessitant une revue du profil d'innocuité du médicament étudié. de même, des événements imprévus ou de nouvelles informations relatives au médicament étudié, au vu desquels les objectifs de l'étude ne seront vraisemblablement pas atteints, pourront amener le promoteur à interrompre prématurément l'étude. en cas d'arrêt prématuré de l'étude, le promoteur informera l'ansm et le cpp sans délai et au maximum dans un délai de 15 jours. les données seront collectées dans un cahier d'observation électronique (e-crf) via le logiciel clinfile©, proposant un hébergement sécurisé des données, certifié iso/iec 27001. toutes les données seront saisies dans l'e-crf par l'équipe d'investigation de l'étude. un numéro d'identification unique sera attribué à chaque patient, permettant la pseudonymisation des données. pour chaque patient, les données directement identifiantes ne seront pas saisies dans l'e-crf (i.e. seuls le numéro d'inclusion, la date d'inclusion, la première lettre du nom, la première lettre du prénom, le mois et l'année de naissance seront recueillis). un fichier de correspondance permettant de faire le lien entre la base pseudonymisée et l'identité des patients sera conservé dans le classeur investigateur. l'e-crf sera créé, testé et validé avant le début de la saisie des données. les données nécessaires à la réponse aux critères de jugement principal et secondaires seront monitorées à intervalles réguliers tout au long de l'essai. les données seront monitorées à l'aide de règles prédéfinies de gestion des données et des requêtes seront automatiquement éditées. tous les efforts raisonnables devront être faits pour compléter les données le plus tôt possible. l'investigateur principal est responsable de l'exactitude et de l'exhaustivité des données enregistrées dans le cahier d'observation. après contrôle et validation, la base de données sera gelée et exportée pour analyse. code recherche mdl_2020_10 eudract 2020-001667-85 21/40 les examens notés s sont réalisés dans le cadre du soin et ceux notés r sont ajoutés du fait de la recherche. les contraintes liées au protocole sont considérées comme minimes. elles relèvent de l'examen irm réalisé après 30 jours de traitement, spécifiquement pour les besoins de la recherche. les tests olfactifs font partie du soin courant. la durée de l'examen irm sera d'environ 20 minutes. les patients pourront participer simultanément à une autre recherche, si le médecin investigateur considère qu'elle n'interfère pas avec cette étude. aucune indemnisation n'est prévue pour la participation des patients.  principe actif : budésonide  excipients : edétate disodique, chlorure de sodium, polysorbate 80, acide citrique, citrate de sodium, eau pour préparations injectables il s'agit d'une étude ouverte. le conditionnement du médicament ne sera pas modifié. le circuit et les numéros de lot devront être tracés. un contre-étiquetage sera réalisé par la pharmacie de chaque centre afin d'identifier les traitements de l'étude. le pharmacien s'engagera à ce que cet étiquetage n'occulte pas les mentions originales du produit commercial. les traitements seront commandés par la pharmacie responsable des essais cliniques de chaque centre. le pharmacien/préparateur en pharmacie procédera au contre-étiquetage du conditionnement secondaire, conformément à la règlementation en vigueur. chaque centre investigateur pourra se fournir chez son fournisseur (même laboratoire pour le budésonide et le nacl 0,9 % 250 ml). la traçabilité des traitements expérimentaux sera assurée conformément à la règlementation des essais cliniques. le circuit des traitements, les documents de traçabilité et les modalités de distribution et d'administration seront répertoriés dans les procédures circuit pharmaceutique. l'observance quotidienne des patients quant à la réalisation des lavages de nez et de la rééducation olfactive sera suivie à l'aide du carnet patient. le traitement sera administré localement en lavage de nez (3 seringues de 20cc dans chaque narine matin et soir). les modalités de reconstitution des traitements et de réalisation des lavages de nez seront expliquées dans le carnet patient qui sera remis avec les traitements. aucune adaptation de posologie n'est prévue. le traitement pourra être interrompu transitoirement en cas de survenue d'effets indésirables. dans le groupe expérimental, il est déconseillé d'administrer conjointement un corticoïde, par voie inhalée ou orale ainsi qu'un inhibiteur puissant du cyp3a4 (bocéprevir, clarithromycine, cobicistat, érythomycine, itraconazole, kétoconazole, posaconazole, ritonavir, télithromycine, voriconazole). il n'existe aucun traitement de secours pour contrecarrer l'effet du médicament expérimental. évènement indésirable : toute manifestation nocive survenant chez une personne qui se prête à une recherche impliquant la personne humaine que cette manifestation soit liée ou non à la recherche ou au produit sur lequel porte cette recherche. effet indésirable : toute réaction nocive et non désirée à un médicament expérimental quelle que soit la dose administrée. : tout évènement (ou effet) indésirable qui :  entraîne la mort,  met en jeu le pronostic vital de la personne qui se prête à la recherche,  nécessite une hospitalisation ou la prolongation d'une l'hospitalisation,  provoque une incapacité ou un handicap important ou durable,  se traduit par une anomalie ou une malformation congénitale (exposition intra utero),  ainsi que tout évènement (ou effet) considéré comme médicalement significatif (c'est à dire ayant des conséquences cliniques importantes mais ne correspondant pas à l'un des autres critères de gravité). et s'agissant du médicament, quelle que soit la dose administrée. effet indésirable inattendu : tout effet indésirable du produit dont la nature, la sévérité, la fréquence ou l'évolution ne concorde pas avec les informations de référence sur la sécurité mentionnées dans le résumé des caractéristiques du produit ou dans la brochure pour l'investigateur lorsque le produit n'est pas autorisé. lien de causalité : relation entre l'événement indésirable et le médicament (ou l'étude). les facteurs à prendre en compte pour la détermination de l'imputabilité sont : les critères chronologiques (délai de survenue de l'effet indésirable, évolution de l'effet indésirable à l'arrêt du traitement, réapparition à la reprise), et les critères sémiologiques (mécanisme d'action ou explication pharmacodynamique, facteurs favorisants ou antécédents similaires, diagnostics différentiels possibles, examens complémentaires prouvant la cause).  non lié : l'évènement est clairement lié à d'autres causes comme non lié : l'évènement est clairement lié à d'autres causes comme une progression de la maladie, un traitement concomitant, une maladie intermittente  possiblement lié : évènement clinique ou biologique avec une relation chronologique et sémiologique compatible intensité : l'intensité des événements est évaluée par l'investigateur selon la classification suivante : grade 1 : léger ; asymptomatique ou symptômes légers ; diagnostic à l'examen clinique uniquement ; ne nécessitant pas de traitement -grade 2 : modéré ; nécessitant un traitement minimal, local ou noninvasif ; interférant avec les activités instrumentales de la vie quotidienne -grade 3 : sévère ou médicalement significatif mais sans mise en jeu immédiate du pronostic vital ; indication d'hospitalisation ou de prolongation d'hospitalisation ; invalidant ; interférant avec les activités élémentaires de la vie quotidienne -grade 4 : mise en jeu du pronostic vital ; nécessitant une prise en charge en urgence -grade 5 : décès lié à l'ei incident : fait susceptible d'affecter la qualité et la sécurité d'emploi du produit et donc de représenter un risque pour la santé des personnes. cet incident peut survenir au cours de la chaîne de fabrication du produit de santé et jusqu'à son utilisation. il est susceptible d'entraîner un effet indésirable. incident grave : incident susceptible d'entraîner des effets indésirables graves. fait nouveau : il s'agit de toute nouvelle donnée pouvant conduire à :  une réévaluation du rapport des bénéfices et des risques de la recherche ou du produit objet de la recherche  des modifications dans l'utilisation de ce produit, dans la conduite de la recherche, ou des documents relatifs à la recherche  ou à suspendre ou interrompre ou modifier le protocole de la recherche ou des recherches similaires. pour les essais portant sur la première administration ou utilisation d'un produit de santé chez des personnes qui ne présentent aucune affection : tout effet indésirable grave. un fait nouveau peut également correspondre à une suspicion d'effet indésirable grave inattendu (susar). pour les essais portant sur la première administration ou utilisation d'un produit de santé chez des personnes qui ne présentent aucune affection : tout effet indésirable grave est considéré comme un fait nouveau. l'investigateur reporte les évènements indésirables dans le cahier d'observation. il évalue pour chaque évènement indésirable, son intensité, sa gravité et le lien de causalité avec la procédure/la technique étudiée (ou comparative) ou avec les autres traitements éventuels. les évènements indésirables couvrent également les erreurs médicamenteuses et les utilisations non prévues par le protocole y compris les mésusages ou l'abus de médicament. l'investigateur notifie sans délai dès qu'il en a connaissance les événements indésirables graves (eig) au promoteur, à l'aide du « formulaire de notification d'eig ». l'évolution clinique ainsi que les résultats des éventuels bilans cliniques et des examens diagnostiques et/ou de laboratoire, ou toute autre information permettant une analyse adéquate du lien de causalité de l'eig sont à préciser : -soit sur la notification initiale d'eig s'ils sont immédiatement disponibles, -soit ultérieurement et le plus rapidement possible, sur un nouveau « formulaire de notification d'eig » de suivi (le 1er suivi à adresser dans les 8 jours après la notification initiale). l'investigateur communique au promoteur tous les renseignements complémentaires demandés (compte-rendu d'examens complémentaires, compte-rendu d'hospitalisation, résultats d'autopsie, etc.). chaque document transmis par l'investigateur devra comporter l'acronyme de la recherche et l'identifiant du patient attribué dans le cadre de la recherche. l'original des documents transmis est conservé sur le site d'investigation. tout patient présentant un eig recevra la prise en charge adaptée à son état et sera suivi jusqu'à la résolution de l'événement ou à un retour à l'état antérieur. si cela s'avère nécessaire, le médicament expérimental sera arrêté. tout eig doit être notifié au promoteur :  à partir de la date de signature du consentement,  jusqu'à la fin de participation à la recherche, mais également sans limitation de temps, lorsque l'eig est susceptible d'être dû au médicament. l'investigateur notifie sans délai dès qu'il en a connaissance au promoteur toute suspicion de réapparition de symptômes d'infection à covid-19 (fièvre, toux, gêne thoracique, dyspnée, asthénie …), à l'aide du « formulaire de notification d'eig » car ils nécessitant une vigilance particulière (s'ils ne répondent pas à la définition des eig, ils seront classés comme « médicalement significatifs). les évènements indésirables graves ne devant pas être notifiés immédiatement au promoteur sont :  une hospitalisation pour une procédure médicale/chirurgicale prévue avant l'inclusion ou prévue dans le protocole ;  une hospitalisation pour une pathologie présente avant l'inclusion et ne s'aggravant pas en cours d'étude ;  une circonstance de vie n'ayant aucune incidence sur l'état de santé et ne nécessitant aucune intervention médicale/chirurgicale (ex : prolongation d'hospitalisation en attendant une place dans un autre service ou établissement, hospitalisation pour cause d'aidants indisponibles, etc…). pour chaque eig, le promoteur (le vigilant) évalue de son côté la gravité et le lien avec le médicament, il juge du caractère attendu (listé) ou inattendu selon le document de référence. il sollicite l'investigateur (ou l'arc/tec de l'étude), pour obtenir les informations complémentaires sur les circonstances de survenue de l'eig, son traitement et son évolution. il code l'eig selon la méthode meddra et rédige le narratif de l'eig en anglais le promoteur déclare à l'ansm toute suspicion d'effet indésirable grave inattendu (susar : suspected unexpected serious adverse reaction) : • en cas de décès ou de mise en jeu du pronostic vital : sans délai à compter du jour où il en a connaissance • dans les autres cas ; au plus tard dans un délai de 15 jours à compter du jour où il en a connaissance les informations complémentaires pertinentes doivent être adressées dans les 8 jours. le promoteur informe les investigateurs de l'étude des suspicions d'effets indésirables graves inattendus qui pourraient avoir un impact défavorable sur la sécurité des personnes qui se prêtent à la recherche. en cas de survenue d'un fait nouveau durant l'étude, le promoteur en informe sans délai, l'ansm et le cpp en précisant les éventuelles mesures de sécurité prises les informations complémentaires pertinentes doivent être adressées dans les 8 jours. de plus, en cas : -d'arrêt de la recherche : le promoteur déclare la fin de la recherche sans délai et au plus tard dans les 15 jours. -de modification substantielle : le promoteur dépose une demande de modification substantielle dans un délai de 15 jours. une fois par an pendant toute la durée de la recherche, le promoteur rédige un rapport de sécurité. ce rapport de sécurité comprend notamment une analyse globale du profil de sécurité du protocole de l'étude prenant en compte toutes les nouvelles données pertinentes de sécurité. les informations de sécurité apparaissent sous forme de tableaux de synthèse résumant les évènements ou effets indésirables graves survenus au cours de la recherche. la date de début du rapport est la date d'autorisation initiale de l'ansm. ce rapport est envoyé électroniquement à l'ansm et au cpp dans un délai de 60 jours suivant la date anniversaire de l'autorisation par l'ansm. dans le cas de cette recherche prévue sur quelques mois, le promoteur rédigera un rapport de sécurité ayant comme date de fin, le dernier suivi du dernier patient inclus. un comité de surveillance indépendant sera mis en place pour cette étude. il inclura un méthodologiste, un orl et un infectiologue, tous trois indépendants de l'étude et n'exerçant pas au sein des centres investigateurs. une charte de fonctionnement a été rédigée concernant le fonctionnement de ce comité. les comptes rendus de réunions du csi seront fournis à l'ansm dès que disponibles. nous faisons l'hypothèse que le pourcentage de patients présentant une amélioration olfactive dans le groupe contrôle sera d'environ 50% après 30 jours. afin de mettre en évidence une différence de 25% entre les deux bras (50% versus 75% de patients présentant une amélioration olfactive dans le bras traité par budésonide), environ 60 patients par bras sont nécessaires, soit un total de 120 participants (formulation bilatérale, puissance=0,8, alpha=0,05). l'analyse statistique sera réalisée sous la responsabilité du service de recherche clinique de la fondation adolphe de rothschild. l'ensemble des patients randomisés ayant reçu au moins une dose de traitement seront pris en compte dans les analyses. un diagramme de flux établi selon les recommandations consort résumera le nombre de patients screenés, inclus, randomisés, perdus de vue et analysés pour chaque bras de randomisation. les raisons de non-participation à chaque étape seront décrites. une analyse descriptive des données sera réalisée. cette analyse comportera des estimations ponctuelles, nombres et pourcentages pour les variables qualitatives, moyenne, écart-type, médiane et range pour les variables quantitatives. la normalité des variables continues sera évaluée graphiquement et/ou à l'aide d'un test de normalité (e.g. shapiro-wilk). une description des données manquantes de chaque variable (effectif et pourcentage) sera réalisée. la comparabilité à la baseline entre le bras expérimental et le bras contrôle sera évaluée au moyen d'un test t de student (ou test de mann-whitney si nécessaire) pour les paramètres continus et d'un test de chi 2 (ou test exact de fisher si nécessaire) pour les paramètres qualitatifs. l'analyse du critère de jugement principal sera réalisée à l'aide d'un modèle de régression logistique, ajusté sur le centre. les objectif et critères de jugement secondaires de l'étude sont : 1-objectif : chez les patients ayant totalement récupéré après 30 jours de traitement, évaluer la persistance de la récupération olfactive 1 mois après l'arrêt du traitement. critère : pourcentage de patients ayant une amélioration de plus de 2 points au score odoratest 30 jours après la fin du traitement (i.e. 60 jours après la randomisation). objectif : dans le groupe traité par budésonide, chez les patients covid-19 n'ayant pas totalement récupéré après 30 jours de traitement, évaluer l'intérêt d'une poursuite du budésonide pendant 30 jours supplémentaires. critère : pourcentage de patients ayant une amélioration de plus de 2 points au score odoratest après 60 jours de traitement par budésonide. objectif : dans le groupe contrôle, chez les patients covid-19 n'ayant pas totalement récupéré après 30 jours de traitement, évaluer l'intérêt de la mise en place d'un traitement par budésonide pendant 30 jours. critère : pourcentage de patients ayant une amélioration de plus de 2 points au score odoratest 30 jours après l'initiation d'un traitement par budésonide (i.e. 60 jours après la randomisation). objectif : rechercher une association entre la présence d'une obstruction à l'irm et la sévérité de la perte olfactive, lors de l'inclusion et après 30 jours de traitement. critère : présence d'un comblement inflammatoire de la fente olfactive à l'irm ou présence d'une atteinte neurologique au niveau du bulbe olfactif. objectif : evaluer la tolérance du budénoside. critère : description des évènements indésirables et événements indésirables graves. l'ensemble des tests seront réalisés selon une formulation bilatérale. une valeur de p < 0.05 sera considérée comme statistiquement significative. non applicable. pour l'analyse du critère de jugement principal, en cas de données manquantes, une imputation sera réalisée selon la méthode bocf (baseline observation carried forward) : les patients non évalués à j30 seront considérés comme n'ayant pas présenté d'amélioration des capacités olfactives. des modifications à la stratégie initiale pourront être apportées, en fonction notamment de l'avancement de l'étude, et reprises dans le plan d'analyse statistique qui sera rédigé juste avant le gel de la base de données. les éventuelles modifications à apporter au plan d'analyse statistique seront proposées par le méthodologiste de l'étude et validées par consensus avec le statisticien et l'investigateur principal. la fondation adolphe de rothschild est promoteur de cette recherche impliquant la personne humaine, de type interventionnelle, selon l'article l1121-1 1 er alinéa du code de la santé publique, modifié par ordonnance n°2016-800 du 16 juin 2016 (art. 1). le présent protocole fera l'objet d'une demande d'autorisation auprès de l'autorité compétente (ansm). l'autorité compétente, définie à l'article l. 1123-12, modifié par ordonnance n°2016-800 du 16 juin 2016, se prononce au regard de la sécurité des personnes qui se prêtent à une recherche interventionnelle, en considérant notamment la sûreté et la qualité des produits utilisés au cours de la recherche conformément, le cas échéant, aux référentiels en vigueur, leur condition d'utilisation et la sécurité des personnes au regard des actes pratiqués et des méthodes utilisées ainsi que les modalités prévues pour le suivi des personnes. elle se prononce en outre sur la pertinence de la recherche, le caractère satisfaisant de l'évaluation des bénéfices et risques attendus et le bien-fondé des conclusions. en accord avec l'article l.1123-6 du code de santé publique modifié par ordonnance n°2016-800 du 16 juin 2016 (art 3.), cette recherche impliquant la personne humaine est soumise à l'avis d'un cpp désigné de manière aléatoire, sans lequel elle ne pourra débuter. l'avis de ce comité sera notifié à l'autorité compétente par le promoteur avant le démarrage de la recherche. le promoteur et les investigateurs s'engagent à ce que cette recherche soit réalisée en conformité avec les dispositions législatives en vigueur, les bonnes pratiques cliniques et la déclaration d'helsinki. les investigateurs s'engagent à respecter le protocole en tout point en particulier en ce qui concerne le recueil du consentement et la notification et le suivi des événements indésirables graves. un exemplaire de l'engagement de responsabilités daté et signé par les investigateurs sera remis au représentant du promoteur. dès la première inclusion, le promoteur informera sans délai l'ansm et le cpp de la date effective de démarrage de l'étude. la date effective de démarrage correspond à la date de signature du consentement par la première personne qui se prête à la recherche. la date de fin d'étude sera transmise par le promoteur à l'ansm et au cpp dans un délai de 90 jours. la date de fin de la recherche correspond au terme de la participation de la dernière personne qui se prête à la recherche, ou le cas échéant, au terme défini dans le protocole. une note d'information précisant les informations à fournir selon l'article 13 du règlement général sur la protection des données de l'union européenne (rgpd) et soumise préalablement au cpp, sera expliquée et remise aux patients qui peuvent refuser de participer à la recherche, comme précisé dans le document. le détail de la procédure d'information est mentionné plus haut dans ce protocole. l'information donnée aux personnes et le recueil de leur consentement doivent être notés et datés dans le dossier médical du patient. en cas de refus de participation, le patient bénéficiera de la prise en charge habituelle. lorsque cette recherche sera terminée, la personne qui se prête à la recherche pourra être informée des résultats globaux selon les modalités qui lui seront précisées dans le document d'information. les informations relatives aux droits des personnes participant à cette recherche (droit d'accès et de rectification, droit d'opposition à la transmission des données couvertes par le secret professionnel susceptibles d'être utilisées dans le cadre de cette recherche) sont intégrées dans la note d'information. l'investigateur coordonnateur informera le promoteur de tout projet de modification du protocole. le promoteur est seul autorisé à modifier le protocole et décidera si la modification envisagée relève ou non d'une modification substantielle. la demande de modification sera adressée par le promoteur à l'ansm et/ou au cpp pour autorisation et avis selon les cas. on entend par modifications substantielle : les modifications qui ont un impact significatif sur tout aspect de la recherche, notamment sur la protection des personnes, y compris à l'égard de leur sécurité, sur les conditions de validité de la recherche, le cas échéant sur la qualité et la sécurité des produits expérimentés, sur l'interprétation des documents scientifiques qui viennent appuyer le déroulement de la recherche ou sur les modalités de conduite de celle-ci. une modification non substantielle du protocole est une modification mineure ou une clarification sans retentissement sur la conduite de l'essai. dès réception de l'avis et/ou de l'autorisation, la version amendée du protocole sera alors transmise à tous les investigateurs par le promoteur. cette recherche est soumise à la loi n°78-17 du 6 janvier 1978 relative à l'informatique, aux fichiers et aux libertés modifié par la loi n°2018-493 du 20 juin 2018 relative à la protection des données personnelles, ainsi qu'au règlement général sur la protection des données de l'union européenne (rgpd). dans le cadre du traitement de données de santé à des fins de recherche scientifique, cette recherche est soumise à l'article 9 du rgpd, alinéas i et j de l'article 9.2. une méthodologie de référence spécifique au traitement de données personnelles opéré dans le cadre des recherches impliquant la personne humaine, de type interventionnelle, a été établie par la cnil (mr-001). cette méthodologie permet une procédure de déclaration simplifiée lorsque la nature des données recueillies dans la recherche et leur traitement sont compatibles avec le document de référence de la cnil. les données recueillies au cours de l'étude ne mentionneront ni le nom ni le prénom des patients inclus, mais seront codées. les renseignements obtenus seront sauvegardés sur fichier informatique. seules les personnes directement impliquées dans l'étude seront habilitées à intervenir sur ces fichiers. les informations relatives aux droits des personnes participant à cette recherche (droit d'accès et de rectification, droit d'opposition à la transmission des données couvertes par le secret professionnel susceptibles d'être utilisées dans le cadre de cette recherche) seront intégrées dans les notes d'information. l'investigateur garantira l'accès aux données sources pour le moniteur, l'auditeur ou l'inspecteur de l'autorité administrative compétente. il s'engage à accepter les contrôles du promoteur et à fournir l'accès aux données sources (dossiers médicaux, fichiers informatiques, documents de l'étude,…). des visites de monitoring seront effectuées dans chaque centre selon une fréquence définie par le promoteur. lors de ces visites sur site en accord avec l'investigateur, les éléments suivants sont revus : -respect du protocole et des procédures qui y sont rattachées, -assurance qualité des données recueillies dans le cahier d'observation : exactitude, données manquantes, cohérence des données, contrôle des documents sources. les participants ont un droit de limitation de traitement de leurs données personnelles selon les conditions décrites à l'article 18 du rgpd. les données pourront être consultées uniquement par le personnel autorisé dans le cadre d'un contrôle qualité. les documents et données relatifs à cette recherche seront archivés par l'investigateur et par le promoteur, pour une durée de 15 ans après la fin de la recherche. cet archivage indexé comporte : -les copies de l'autorisation de l'ansm -les copies de l'avis du cpp -les versions successives du protocole (identifiées par le n° de version et la date de version) -les courriers de correspondance entre promoteur et les investigateurs -le cahier d'observation complété et validé de chaque sujet inclus -les formulaires de consentement -toutes les annexes spécifiques à l'étude (notamment le cv des investigateurs) -le rapport final de l'étude provenant de l'analyse statistique et du contrôle qualité de l'étude (double transmis au promoteur) -les certificats d'audits éventuels réalisés au cours de la recherche -la base de données ayant donné lieu à l'analyse statistique, devant aussi faire l'objet d'archivage par le responsable de l'analyse (support papier ou informatique) 10 assurance et financement dans cette recherche impliquant la personne humaine, de type interventionnelle, la fondation adolphe de rothschild, en tant que promoteur, contractera auprès de la sham une police d'assurance pour toute la durée de la recherche. cette assurance garantira sa propre responsabilité civile ainsi que celle de tout intervenant (médecin ou personnel impliqué dans la réalisation de la recherche), indépendamment de la nature des liens existant entre les intervenants et le promoteur (article l1121-10 du code de la santé publique, modifié par loi n°2012-300 du 5 mars 2012art. 1 et article r 1121-4, modifié par décret n°2106-1537 du 16 novembre 2016art.3). le promoteur prendra en charge les frais supplémentaires liés aux fournitures ou examens spécifiquement requis par le protocole de la recherche pour la mise en oeuvre de celui-ci. lorsque la recherche est réalisée dans un établissement de santé, la prise en charge de ces frais fait l'objet d'une convention entre le promoteur et le représentant légal de cet établissement. 11 règles relatives à la publication et rapport final 11 .1 enregistrement de l'étude l'étude sera enregistrée sur un site web en libre accès (e.g. https://clinicaltrials.gov/) avant l'inclusion du premier patient. le rapport d'étude final mentionné à l'article r.1123-67 du code de la santé publique sera rédigé et signé par le promoteur et l'investigateur. les résultats de l'étude seront transmis dans la base eudract dans un délai d'un an suivant la fin de l'essai, c'est-à-dire au terme de la participation de la dernière personne qui se prête à la recherche. conformément à l'article r 5121-13 du code de la santé publique, les essais ne peuvent faire l'objet d'aucun commentaire écrit ou oral sans l'accord conjoint de l'investigateur et du promoteur. la fondation adolphe de rothschild, promoteur de l'étude, est propriétaire des données et des résultats de l'étude. aucune utilisation ou transmission à un tiers ne peut être effectuée sans son accord préalable. les communications et publications des résultats de l'étude seront réalisées sous la responsabilité de l'investigateur coordonnateur avec l'accord des investigateurs et des autres coauteurs associés. elles devront décrire de façon honnête et équilibrée tous les aspects de l'étude sans tenir compte d'autres intérêts, notamment non scientifiques. les coauteurs des publications seront les investigateurs et les cliniciens impliqués (au prorata de leur contribution), le méthodologiste et le biostatisticien référent de l'étude, et les chercheurs associés (à définir selon le cas). les autres membres du personnel du service de recherche clinique ayant activement participé à l'élaboration, au déroulement du protocole et à la rédaction des résultats devront également être cités. les règles de publications suivront les recommandations du réseau equator (https://www.equator-network.org/reporting-guidelines/). la fondation adolphe de rothschild sera mentionnée comme étant le promoteur de la recherche. cette dernière a la maîtrise de la première publication. toute requête pour cacher des résultats, changer et atténuer le contenu du rapport final ou des publications sera systématiquement rejetée par le promoteur. l'investigateur adressera une copie des publications au promoteur. la rééducation olfactive utilise des odorants aromatiques, faciles à se procurer (même en période de confinement). elle est composée de 6 odorants : vanille, clou de girofle, vinaigre, curry, cannelle et thym. les early clinical and ct manifestations of coronavirus disease 2019 (covid-19) pneumonia sixty seconds on olfactory neuropathy in severe acute respiratory syndrome: report of a case the relationship of olfactory function and clinical traits in major depressive disorder viral kinetics and antibody responses in patients with covid-19. medrxiv preprint clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study therapeutic use of steroids in non-chronic rhinosinusitis olfactory dysfunction: a systematic evidence-based review with recommendations. int forum allergy rhinol budesonide irrigation with olfactory training improves outcomes compared with olfactory training alone in patients with olfactory loss. int forum allergy rhinol olfactory dysfunction and its measurement in the clinic a new clinical olfactory test to quantify olfactory deficiences a new standardized format for reporting hearing outcome in clinical trials annexe 1. test olfactif odoratest l'olfactomètre utilisé pour cette étude permet de déterminer le seuil olfactif pour cinq odorants purs, facilement reconnaissables tels le phenylethyl alcool (odeur 1) évoquant l'odeur de rose ou fleur la première série est présentée pour un ordre aléatoire en concentrations décroissantes, et il s'agit encore d'un exercice de familiarisation les réponses données par le patient seront enregistrées et permettront de donner un seuil de détection et d'identification pour chaque odeur annexe 2. questionnaire d'auto-évaluation l'objectif de ce questionnaire est d'évaluer comment les gens perçoivent des changements dans leur sens du goût et de l'odorat sur une échelle allant de 0 (pas de goût) à 10 (goût normal), à combien évaluez-vous votre goût aujourd ce goût persistant est (entourez toutes les réponses qui conviennent) si je compare mon sens du goût maintenant relativement à avant de tomber malade : • je perçois le goût salé (entourez une seule réponse) je qualifierais cette anomalie de mon sens du goût comme (entourez une seule réponse) sur une échelle allant de 0 (pas d'odorat) à 10 (odorat normal), à combien évaluez-vous votre odorat aujourd si je compare mon sens de l'odorat maintenant relativement à avant de tomber malade, les odeurs sont je ne sens rien du tout je qualifierais cette anomalie de mon sens de l'odorat comme (entourez une seule réponse) cette perturbation du sens de l'odorat affecte ma qualité de vie de manière (entourez une seule réponse) key: cord-300465-19euup51 authors: paniagua-avila, alejandra; fort, meredith p.; glasgow, russell e.; gulayin, pablo; hernández-galdamez, diego; mansilla, kristyne; palacios, eduardo; peralta, ana lucia; roche, dina; rubinstein, adolfo; he, jiang; ramirez-zea, manuel; irazola, vilma title: evaluating a multicomponent program to improve hypertension control in guatemala: study protocol for an effectiveness-implementation cluster randomized trial date: 2020-06-09 journal: trials doi: 10.1186/s13063-020-04345-8 sha: doc_id: 300465 cord_uid: 19euup51 background: hypertension is a major risk factor for cardiovascular disease (cvd). despite advances in hypertension prevention and treatment, the proportion of patients who are aware, treated and controlled is low, particularly in low-income and middle-income countries (lmics). we will evaluate an adapted version of a multilevel and multicomponent hypertension control program in guatemala, previously proven effective and feasible in argentina. the program components are: protocol-based hypertension treatment using a standardized algorithm; team-based collaborative care; health provider education; health coaching sessions; home blood pressure monitoring; blood pressure audit; and feedback. methods: using a hybrid type 2 effectiveness-implementation design, we will evaluate clinical and implementation outcomes of the multicomponent program in guatemala over an 18-month period. through a cluster randomized trial, we will randomly assign 18 health districts to the intervention arm and 18 to enhanced usual care across five departments, enrolling 44 participants per health district and 1584 participants in total. the clinical outcomes are (1) the difference in the proportion of patients with controlled hypertension (< 130/80 mmhg) between the intervention and control groups at 18 months and (2) the net change in systolic and diastolic blood pressure from baseline to 18 months. the context-enhanced reach, efficacy, adoption, implementation, maintenance (re-aim)/practical robust implementation and sustainability model (prism) framework will guide the evaluation of the implementation at the level of the patient, provider, and health system. using a mixed-methods approach, we will evaluate the following implementation outcomes: acceptability, adoption, feasibility, fidelity, adaptation, reach, sustainability, and cost-effectiveness. discussion: we will disseminate the study findings, and promote scale up and scale out of the program, if proven effective. this study will generate urgently needed data on effective, adoptable, and sustainable interventions and implementation strategies to improve hypertension control in guatemala and other lmics. trial registration: clinicaltrials.gov: nct03504124. registered on 20 april 2018. hypertension is the leading preventable risk factor for cardiovascular disease (cvd), premature death and disability worldwide [1] . it contributes to the burden of cardiovascular disease and chronic kidney disease worldwide, particularly in low-income and middleincome countries (lmics) [2, 3] . it is estimated that 31.1% of the adult population had hypertension in 2010, three quarters of whom were living in lmics [3] . while its prevalence is steady or decreasing in high-income countries, it increased by 7.7% from 2000 to 2010 in lmics [3, 4] . in latin america, hypertension is the most important risk factor for coronary heart disease and stroke [5] . however, the proportion of patients who are aware, treated and controlled is low. a survey conducted in guatemala showed that the prevalence of hypertension in adults older than 40 years is 41%, while only 61% are aware of their condition and only half of those who are aware usually take antihypertensive medications [6] . despite the availability of evidence-based hypertension treatment guidelines, multiple barriers hinder the appropriate management of hypertension in primary care settings. hypertension guidelines recommend antihypertensive medications and individualized lifestyle changes, which include weight loss, physical activity, reduced alcohol and sodium intake, and a diet rich in fruits and vegetables and in low-fat dairy products with reduced saturated and total fat (dietary approaches to stop hypertension, dash) [7] [8] [9] [10] [11] [12] . our formative needs assessment documented several limitations related to hypertension management in guatemala, including a limited health budget for the treatment of non-communicable diseases, fragmented governance and service delivery, inadequate training of the healthcare workforce, and shortage of essential hypertensive medications and basic equipment, particularly at frontline facilities [13] . in addition, an overarching challenge is the prioritization of infectious diseases and maternal and child health over non-communicable diseases [13] . in other countries, barriers for implementing hypertension treatment guidelines at the primary care level include organizational-level obstacles, communication problems between the primary and secondary levels of care, multiple competing demands on physicians' time, and lack of reimbursement for preventive counseling [14, 15] . many implementation strategies targeting healthcare administration, facilities, providers, and patients have been proven effective at improving hypertension control. specifically, these strategies include team-based care, health coaching sessions, home-based blood pressure (bp) monitoring, clinical decision support, bp audit and feedback, and training of healthcare providers. moreover, a combination of strategies is more effective than individual ones [16] . this study is an implementation-effectiveness, hybrid, type 2, cluster randomized control trial that will evaluate a multilevel and multicomponent hypertension control program within the guatemalan primary care system [17] . through a formative mixed-methods assessment and adaptation workshops, we have adapted the effective hypertensive control program in argentina (hcpia) and other implementation strategies to the guatemalan context [13] . the multicomponent program includes a protocol-based hypertension treatment and five implementation strategies: team-based collaborative care, health provider education, health coaching sessions, home blood pressure monitoring, and blood pressure audit and feedback. this program targets the first level (health posts) and second level (health centers) of care in the public health system. the guatemalan public health system serves 70% of the population and is organized in three levels of care [18] . the first, second, and third levels comprise health posts, health centers, and hospitals, which serve the community, municipal, and the regional level, respectively. health posts are staffed by auxiliary nurses, while health centers are staffed by general physicians, professional nurses, auxiliary nurses and, in some cases, psychologists or social workers. health posts and health centers are responsible for providing promotional, preventative, and primary care services. health districts represent the municipal administration. the three levels of care are connected by referral networks with the goal of decentralizing health services and increasing access to care. however, the vast majority of healthcare providers and facilities are concentrated in urban areas, leaving rural communities with limited access to health services [18] . we are conducting this study within the first (health posts) and second (health centers) levels of care. with approval from the ministry of health, we selected 36 health districts distributed in five departments: baja verapaz (n = 4), chiquimula (n = 10), huehuetenango (n = 10), sololá (n = 10), and zacapa (n = 2). the study will be implemented at the health center and 1-2 health posts per health district, making a total of 36 health centers and 71 health posts (see fig. 1 ). the eligibility criteria for health districts are the following: 1. having at least one health post with two or more auxiliary nurses and basic infrastructure to store clinical charts 2. serving rural and semirural communities 3. having at least one professional nurse or physician per health district, responsible for supervising the health post(s) the overarching aim of this study is to evaluate the clinical effectiveness and implementation outcomes of a hypertension control multicomponent program within the first and second levels of care in guatemala, compared to usual care. our main hypothesis is that the multicomponent program will improve hypertension control among patients with uncontrolled hypertension treated in the public healthcare system of guatemala. the co-primary objectives are: 1. to test if a multilevel and multicomponent intervention program improves hypertension control among guatemalan hypertensive patients over an 18-month period compared to usual care. 2. to evaluate the acceptability, adoption, feasibility, fidelity, adaptation, reach, and sustainability of implementing the intervention in the primary care setting. the secondary objective is 3. to evaluate the cost-effectiveness of the multilevel and multicomponent intervention program, compared to usual care. study design: implementation-effectiveness cluster randomized controlled trial we are conducting a hybrid type 2 effectivenessimplementation, cluster randomized controlled trial (crct). we have randomly assigned 18 health districts (clusters) to the intervention arm and 18 to enhanced usual care (control arm) across five departments. we will enroll 44 participants per health district and 1584 participants in total. after selecting 36 eligible health districts, and before initiating participant recruitment, health districts were randomized and stratified by department, using a computerized random number generator. the trial flow chart is shown in fig. 2 and the standard protocol items: recommendation for interventional trials (spirit) figure is shown in fig. 3 . the spirit checklist is provided in additional file 1. the study follows minimum eligibility criteria to evaluate the intervention in a real-world setting. men and women 40 years or older with uncontrolled hypertension, and who meet the following eligibility criteria will participate in the study: have uncontrolled hypertension, which will be ascertained by measuring bp at two screening visits, scheduled 1-7 days apart from each other. participants with stage ii hypertension (average systolic bp ≥ 140 mmhg or diastolic bp ≥ 90 mmhg) are eligible. participants with stage i hypertension (average systolic bp 130-139 mmhg or diastolic bp 80-89 mmhg) are eligible if they meet at least one of the following characteristics: (1) taking antihypertensive medications; (2) history of cardiovascular disease (myocardial infarction or stroke); (3) estimated cardiovascular risk higher than 10% in 5 years (based on the nhanes i follow-up study cardiovascular risk estimation) using a noninvasive prediction indicator [19, 20] . live in a community served by one of the 71 participating health posts and willing to receive hypertension care at the health post. be willing to sign an informed consent form before any study procedure is performed. for illiterate patients, a witness who reads and understands the consent will co-sign the informed consent form. individuals who have any of the following exclusion criteria will not be eligible to participate in the study: pregnant according to self-report diagnosed end-stage renal disease or any chronic terminal disease bedridden planning to move from the study area within the next 18 months participants are being recruited from participating health posts and from the community in their catchment area. auxiliary nurses help study staff to identify potential participants and implement the intervention (see below), but do not participate in any study measurement. the study intervention is a multicomponent and multilevel program to improve hypertension control over 18 months. the program is composed of one core intervention and five evidence-based implementation strategies (see fig. 4) , which are defined as methods to enhance the adoption, implementation, and sustainment of the core intervention [21] . the core intervention and implementation strategies were previously adapted to the rural guatemalan context by the study team and stakeholders from the ministry of health and local communities [13] . physicians and nurses working at intervention health centers and auxiliary nurses working at health posts are responsible for delivering the intervention. the study team and ministry of health officials designed a standardized stepped-care hypertension treatment protocol summarized in an algorithm, based on the american heart association (aha) hypertension guidelines 2017 and the guatemala ministry of health healthcare norms 2018 [22, 23] . after participants are enrolled in the study, health district physicians, nurses, and auxiliary nurses will establish an individualized treatment plan for the participant to reach a bp target < 130/80 mmhg, with a combination of antihypertensive medications offered by the ministry of health: hydrochlorothiazide, enalapril and losartan. the study team provided educational materials and pocket cards summarizing the hypertension treatment algorithm to healthcare teams of physicians, nurses, and auxiliary nurses from health posts and health centers will work collaboratively to establish a treatment plan for hypertensive patients. after study enrollment, a physician or nurse will perform a physical examination, confirm the hypertension diagnosis and select the initial anti-hypertensive medications following the standardized hypertension treatment protocol described above. auxiliary nurses from health posts (first level of care) will be in charge of follow up and health coaching sessions, and will coordinate and connect patients with physicians and nurses at the health center (second level of care). the collaborative team will meet at least monthly at the health center to discuss cases of uncontrolled hypertension or adverse events and make clinical decisions following the standardized hypertension treatment protocol. usual care provided by the ministry of health for patients with hypertension does not include team-based collaborative care. the study team provided an interactive 2-day workshop for physicians, nurses and auxiliary nurses, during the second semester of 2019. training content included: bp management using a stepped-care protocol-based hypertension treatment; titration and adverse effects of antihypertensive medications; team-based collaborative care; and motivational interviewing skills to promote medication adherence and healthy lifestyle modifications during health coaching sessions. one month after the training, the study team conducted individualized field certifications on blood pressure measurement and health coaching sessions with auxiliary nurses working in health posts. periodic training will be provided to newly hired providers and as refreshers. usual hypertensive care does not auxiliary nurses conduct health coaching sessions focused on promoting adherence to anti-hypertensive medications, strategies to overcome treatment side effects and lifestyle modifications: reaching or maintaining a healthy weight, limiting sodium and alcohol intake, getting regular physical activity, and adopting an eating plan based on the dietary approaches to stop hypertension (dash). participants receive an educational flipchart adapted from the manual "healthy and happy heart" (corazon sano y feliz), previously developed and piloted in guatemala [24] , and a card to register bp measurements. relatives will be encouraged to participate in health coaching sessions. during the first 3 months of the intervention, health coaching sessions will take place monthly during the first 3 months of the intervention. if the patient meets the bp target, the frequency will be reduced to every 3 months. usual hypertensive care does not include health coaching sessions. after study enrollment, each patient receiving care at one of the intervention health districts obtains an electronic home bp monitor that stores 30 readings with date and time stamp (omron hem-7121). auxiliary nurses will teach patients and literate relatives to measure bp using the electronic monitor and document readings on a card provided by the study team. auxiliary nurses will review the patient card and document mean home bp-readings during the health coaching sessions, which the care team will use to guide hypertension management decisions. home bp monitoring is not part of usual hypertensive care. auxiliary nurses create lists of hypertensive patients documenting their anti-hypertensive medications, adverse events, and their controlled or uncontrolled status. then, auxiliary nurses take these lists to collaborative team meetings, where the group reviews cases and makes management decisions following the standardized hypertension treatment protocol. given that usual hypertensive care does not include completion of patient charts, the study team is providing paper-based forms for auxiliary nurses to generate the lists of patients with hypertension. blood pressure audit and feedback is not included in usual hypertensive care. healthcare providers based at the control health districts will receive a one-morning, 4-h training session on the ministry of health healthcare norms 2018 for hypertension management, conducted by ministry of health representatives. similar to the intervention arm, the study will provide one electronic bp monitor (omron hem-7121) to each health center and health post. at the central government and department levels, the study team will work with ministry of health officials to promote the purchase, distribution and availability of essential hypertensive medications at participating health districts at a minimum. while participants in the intervention group receive an electronic bp monitor (omron hem-7121) at the first study visit, those in the control arm will receive the bp monitor and study-specific educational materials at the last study visit. the primary clinical outcome is the 18-month difference in the proportion of participants with controlled hypertension (bp < 130/80 mmhg) between the intervention and control groups. the secondary clinical outcome is the 18-month net change in systolic and diastolic bp from baseline. the bp measurement for inclusion in the study and used in the outcome analysis will be standardized following the aha guidelines and conducted by trained study staff [22, 25] . the clinical outcomes correspond to intervention effectiveness, measured at the individual participant level. we will also measure implementation outcomes as part of the second co-primary aim. the context-enhanced reach, efficacy, adoption, implementation, maintenance (re-aim)/ practical robust implementation and sustainability model (prism) framework will guide the evaluation of the implementation at the patient, provider, and health system levels. using a mixed-methods approach, we will evaluate the following implementation outcomes: acceptability, adoption, feasibility, fidelity, adaptation, reach, sustainability, and cost effectiveness [26] . the power calculation for the primary outcome was based on the following assumptions: (1) a two-sided significance level of 0.05; (2) statistical power of 90%; (3) a proportion of patients with bp < 130/80 mmhg of 50% in the control group; (4) detectable group differences in proportion of bp < 130/80 mmhg of 15% (65% of patients with bp < 130/80 mmhg in the intervention group); (5) intra-cluster correlation (icc) coefficient for hypertension control of 0.055; (6) 18 clusters (health districts) per group; and (7) 85% follow-up rate by 18 months. the sample size for each cluster is 37 based on a two-sample z test for individual-level comparison of a cluster design. further assuming an 85% follow-up rate by 18 months, we will need to recruit 44 participants from each district and 1584 study participants for the entire study. the statistical power is even higher for the secondary outcomes because they are continuous variables. table 1 shows the statistical power based on various follow-up rates and iccs. the intra-cluster correlation over 18 months was based on our data from the hypertensive control program in argentina (hcpia) [27, 28] . we expect that each health district will enroll at least 44 participants. given the longstanding engagement of ministry of health providers at the community level, we anticipate being able to successfully enroll the total number of participants. to enhance recruitment of participants, we have engaged healthcare providers and community leaders since the preparation phase of the trial. in addition, healthcare providers were familiarized with eligibility criteria and the enrollment process during training workshops and are referring potential study participants to study staff, who maintain constant communication with providers. the primary analysis will be conducted on an intention-to-treat basis. we will compare the proportion of participants who achieve bp control in the intervention arm and the control arm by using logistic mixed-effects regression analysis, where participants and clusters are included as random effects and the intervention group, time, and group-by-time interaction are included as fixed effects. in a secondary analysis, blood pressure values at baseline, 6 months, 12 months, and 18 months will be modeled in a linear mixed-effects regression analysis. pre-defined subgroup analyses by age (< 60 vs. ≥ 60 years), sex (men vs. women), history of cardiovascular disease (cvd) (yes vs. no), and body mass index (< 30 vs. ≥ 30 kg/ m 2 ) will be conducted. further details of the data management, statistical methods, and quality control plans are available upon request from the authors. we will use the context-enhanced re-aim/prism framework to evaluate the implementation of the multicomponent program [29, 30] . the implementation evaluation will allow us to monitor and improve program implementation, understand the relationship between implementation characteristics and health outcomes, and design the dissemination plan if the program is proven effective. we will assess the expanded re-aim/prism dimensions at the patient, provider, and health system levels (see table 2 ). in addition to the five dimensions of re-aim (reach, effectiveness, adoption, implementation and maintenance) we will assess the program fit and sustainability infrastructure of prism [31] . the implementation outcomes that we will measure are: acceptability, adoption, feasibility, fidelity, adaptation, reach, sustainability, and cost effectiveness [26] . we will use a combination of quantitative and qualitative methods to assess the domains of interest. we will gather data during patients' study visits at 6, 12, and 18 months. in addition, we will make regular (1-2 months) visits to healthcare facilities to capture study inputs and ongoing program implementation captured in checklists. in a subset of study sites, we will conduct interviews with participants and family members, providers, and public health administrators using semi-structured interview guides combined with chart-stimulated recall, shadowing, and direct observation. we will perform a cost-effectiveness analysis using the individual patient data collected at follow-up visits (see fig. 3 ), expressed as incremental cost per additional percentage of patients that achieved hypertension control at 18 months. intervention costs will include fixed costs such as education of health providers and salary of auxiliary nurses, and variable costs such as electronic bp monitors. healthcare costs will include ambulatory costs, such as drugs and laboratory tests, and hospital care (hospitalization). protocol-driven costs will be excluded. we will analyze differences in costs following a similar analytical approach as that used for estimating health outcomes [32] . uncertainty around the incremental cost-effectiveness ratio (icer) will be estimated by bootstrapping techniques, and a 95% credible interval will be reported [33, 34] . this is the first randomized cluster trial in central america to test the effect of a multicomponent intervention program for bp control in underserved rural populations. the intervention and study outcomes are patientcentered, and patients, ministry of health provider-teams, and other stakeholders have been engaged at every step of the proposed study. the multicomponent intervention program is designed to address barriers at the healthcare system, provider-team, and patient levels. the proposed study will generate urgently needed data on effective, adoptable, and sustainable intervention strategies aimed at reducing bp-related disease burden in central america and other low-income settings. although the efficacy and effectiveness of lifestyle modifications and antihypertensive drug treatment on the prevention of htn and consequent cvd risk have been demonstrated in randomized controlled trials, this knowledge has not been fully applied in lmic [35, 36] . the proposed study will test whether an evidence-based, multilevel and multicomponent intervention program can be translated to and is feasible in the primary healthcare systems of this region. we will disseminate the study findings, promote scale up, and scale out of the program, if proven effective. this study will generate urgently needed data on effective, adoptable, and sustainable intervention and implementation strategies to improve hypertension control in guatemala and other low-and middle-income countries. a stakeholder engagement process and needs assessment are finalized. the study manual of operations was developed and training of study staff has been completed. the data safety and monitoring board met twice during 2019: prior to study enrollment and during the first semester of enrollment. intervention educational materials for healthcare providers and patients were adapted and finalized. training workshops and field certifications of healthcare providers were developed and completed. the community advisory board was formed with local healthcare providers and hypertensive patients and has met twice. enrollment into the study began in july 2019 and 89% was completed by march 20th 2020. enrollment has been paused due to covid-19 and will reinitiate as soon as a comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the global burden of disease study global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the global burden of disease study global disparities of hypertension prevalence and control: a systematic analysis of population-based studies from 90 countries national, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5·4 million participants risk factors for acute myocardial infarction in latin america: the interheart latin american study central america diabetes initiative (camdi): survey of diabetes, hypertension and chronic disease risk factors longterm effects of weight-reducing interventions in hypertensive patients: systematic review and meta-analysis physical activity in young adults and incident hypertension over 15 years of follow-up: the cardia study effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. hypertens (dallas, tex 1979) effect of longer-term modest salt reduction on blood pressure a clinical trial of the effects of dietary patterns on blood pressure. dash collaborative research group the dash diet, 20 years later stakeholder engagement in the translation of a hypertension control program to guatemala's public primary health care system: lessons learned, challenges, and opportunities. glob heart competing demands of primary care: a model for the delivery of clinical preventive services barriers to detecting and treating hypercholesterolaemia in patients with ischaemic heart disease: primary care perceptions comparative effectiveness of implementation strategies for blood pressure control in hypertensive patients: a systematic review and meta-analysis effectivenessimplementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact the health system of guatemala an assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment instrument in bangladesh laboratorybased versus non-laboratory-based method for assessment of cardiovascular disease risk: the nhanes i follow-up study cohort implementation strategies. in: dissemination and implementation research in health: translating science to practice acc/aha/aapa/abc/acpm/ags/apha/ash/ aspc/nma/pcna guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the american college of cardiology ministerio de salud pública y asistencia social. normas de atencion salud integral para primero y segundo nivel evaluation of a pilot hypertension management programme for guatemalan adults measurement of blood pressure in humans: a scientific statement from the outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in argentina: a randomized clinical trial comprehensive approach for hypertension control in low-income populations: rationale and study design for the hypertension control program in argentina re-aim planning and evaluation framework: adapting to new science and practice with a 20-year review using the practical, robust implementation and sustainability model (prism) to qualitatively assess multilevel contextual factors to help plan, implement, evaluate, and disseminate health services programs evaluating the public health impact of health promotion interventions: the re-aim framework cost-effectiveness analysis alongside clinical trials ii-an ispor good research practices task force report pulling cost-effectiveness analysis up by its bootstraps: a non-parametric approach to confidence interval estimation cost-effectiveness of a comprehensive approach for hypertension control in low-income settings in argentina: trial-based analysis of the hypertension control program in argentina the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the jnc 7 report international society of hypertension low and middle income countries committee: review of the goals of the committee and of 5 years of ish activities in low and middle income countries publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors are grateful for support from all the ministry of health providers and staff that contributed to the adaptation and development of the study intervention, are implementing the study intervention and enhanced usual care activities, and patients and family members. national policies allow. this is study protocol version 6.1 and the version date is 21 may 2019. supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04345-8.additional file 1. spirit 2013 checklist: recommended items to address in a clinical trial protocol.authors' contributions apa wrote the initial draft of the manuscript, incorporated authors' contributions, finalized the manuscript after edits and review by co-authors, designed and developed the tables and figures. km contributed to the development of fig. 1 . vi and mrz wrote content and provided guidance as principal investigators. jh provided guidance as principal investigator. mf wrote content, reviewed the final version of the paper and provided critical review of the implementation science framework and table 2 . rg provided critical review of the implementation evaluation content and table. all authors contributed to the conception and design of the study. all authors contributed to the reviewing and editing iterative drafts. all authors read and approved the final manuscript. research reported in this article was supported by the u.s. national heart, lung, and blood institute of the national institutes of health under award number u01hl138647. the views expressed are those of the authors and do not necessarily represent those of the national heart, lung, and blood institute, the national institutes of health, the department of health and human services, or the u.s. government. upon completion of the trial, datasets used and analyzed during the study are available from the corresponding author on reasonable request. this study was approved by incap institutional review board (irb) and the guatemalan national health ethics committee. in addition, irbs from tulane university school of public health and tropical medicine, institute for clinical effectiveness and health policy in argentina and colorado school of public health approved the study. the study was registered at clinicaltrials.gov (nct03504124) on 20 april 2018. informed consent will be obtained from all participants. not applicable. the authors declare that they have no competing interests. key: cord-033331-giku34r9 authors: manrique-saide, pablo; dean, natalie e.; halloran, m. elizabeth; longini, ira m.; collins, matthew h.; waller, lance a.; gomez-dantes, hector; lenhart, audrey; hladish, thomas j.; che-mendoza, azael; kirstein, oscar d.; romer, yamila; correa-morales, fabian; palacio-vargas, jorge; mendez-vales, rosa; pérez, pilar granja; pavia-ruz, norma; ayora-talavera, guadalupe; vazquez-prokopec, gonzalo m. title: the tirs trial: protocol for a cluster randomized controlled trial assessing the efficacy of preventive targeted indoor residual spraying to reduce aedes-borne viral illnesses in merida, mexico date: 2020-10-08 journal: trials doi: 10.1186/s13063-020-04780-7 sha: doc_id: 33331 cord_uid: giku34r9 background: current urban vector control strategies have failed to contain dengue epidemics and to prevent the global expansion of aedes-borne viruses (abvs: dengue, chikungunya, zika). part of the challenge in sustaining effective abv control emerges from the paucity of evidence regarding the epidemiological impact of any aedes control method. a strategy for which there is limited epidemiological evidence is targeted indoor residual spraying (tirs). tirs is a modification of classic malaria indoor residual spraying that accounts for aedes aegypti resting behavior by applying residual insecticides on exposed lower sections of walls (< 1.5 m), under furniture, and on dark surfaces. methods/design: we are pursuing a two-arm, parallel, unblinded, cluster randomized controlled trial to quantify the overall efficacy of tirs in reducing the burden of laboratory-confirmed abv clinical disease (primary endpoint). the trial will be conducted in the city of merida, yucatan state, mexico (population ~ 1million), where we will prospectively follow 4600 children aged 2–15 years at enrollment, distributed in 50 clusters of 5 × 5 city blocks each. clusters will be randomly allocated (n = 25 per arm) using covariate-constrained randomization. a “fried egg” design will be followed, in which all blocks of the 5 × 5 cluster receive the intervention, but all sampling to evaluate the epidemiological and entomological endpoints will occur in the “yolk,” the center 3 × 3 city blocks of each cluster. tirs will be implemented as a preventive application (~ 1–2 months prior to the beginning of the abv season). active monitoring for symptomatic abv illness will occur through weekly household visits and enhanced surveillance. annual sero-surveys will be performed after each transmission season and entomological evaluations of ae. aegypti indoor abundance and abv infection rates monthly during the period of active surveillance. epidemiological and entomological evaluation will continue for up to three transmission seasons. discussion: the findings from this study will provide robust epidemiological evidence of the efficacy of tirs in reducing abv illness and infection. if efficacious, tirs could drive a paradigm shift in aedes control by considering ae. aegypti behavior to guide residual insecticide applications and changing deployment to preemptive control (rather than in response to symptomatic cases), two major enhancements to existing practice. trial registration: clinicaltrials.gov nct04343521. registered on 13 april 2020. the protocol also complies with the who international clinical trials registry platform (ictrp) (additional file 1). primary sponsor: national institutes of health, national institute of allergy and infectious diseases (nih/niaid). aedes-borne viruses (abvs; e.g., dengue [denv] , chikungunya [chikv] , zika [zikv]) pose a major public health burden worldwide [1] [2] [3] . transmitted primarily by the highly anthropophilic mosquito aedes aegypti, abvs propagate epidemically, inflicting substantial healthcare and development costs on urban tropical populations. model projections estimate that an average of 390 million denv infections occur per year, of which 96 million manifest clinically [4, 5] . explosive denv outbreaks saturate healthcare systems [6] , with worldwide estimates as high as $39 billion (2010 us$) per year spent on costs related to medical care, surveillance, vector control, and lost productivity [7] . the emergence and rapid epidemic propagation of chikv and zikv (and particularly congenital zika) have added significant burden and costs to healthcare systems [8, 9] . given the heavy global burden of abv illness, and in the absence of efficacious vaccines or other therapeutic options, implementation of highly effective and currently available vector control strategies represents the most viable approach for abv prevention [10, 11] . vector control methods such as larval control, source reduction, and space spraying are widely used against abvs [12, 13] . unfortunately, there is limited epidemiological evidence that these methods are adequate to prevent or reduce human abv transmission in a sustainable manner [13, 14] . poorly designed evaluations, a historical lack of focus on quantifying intervention impact using epidemiological endpoints, and limited funding for large-scale randomized controlled trials with epidemiological endpoints have all contributed to the lack of rigorous, evidence-based, assessments of abv vector control interventions [10, 15] . furthermore, the classic deployment of house-based interventions in response to reported clinical abv cases has failed to account for the important contribution of out-of-home human exposure to ae. aegypti [16] and the silent contribution of asymptomatic infections in sustaining infectious virus in local mosquitoes [17] . novel vector control approaches and intervention delivery strategies with proven and robust epidemiological evidence of their impact on abv transmission are urgently needed. indoor residual spraying (irs) is the use of longlasting residual insecticides applied to the walls, eaves, and ceilings of houses or structures targeting vectors that land or rest on these surfaces [18] [19] [20] . the residual component of the application means that, for several weeks or months, the insecticide will kill mosquitoes and other insects that come into contact with treated surfaces. historical evidence has shown that, when expeditiously implemented, residual insecticide applications can significantly reduce abv transmission [21] [22] [23] . despite this evidence, the fact that it is time consuming and dependent on specialized human resources has limited widespread adoption of irs by abv control programs due to the perceived challenge of scaling-up the intervention over large urban areas. in urban settings, adult ae. aegypti typically rest indoors, where they feed frequently and almost exclusively on human blood [24] . studies performed in panama, peru, and mexico have shown that ae. aegypti rest predominantly below heights of 1.5 m, mainly inside bedrooms and on surfaces made of cement, wood, and cloth [25] [26] [27] . selectively applying residual insecticides below 1.5 m and on common mosquito resting surfaces provides an entomological impact similar to spraying entire walls (as performed in classic irs), but in a fraction of the time (< 18%) and insecticide volume (< 30%) compared to classic irs [28] . this selective insecticide application mode is called "targeted indoor residual spraying" (tirs), and it involves the application of residual insecticides on exposed lower sections of walls [< 1.5 m], under furniture, and on dark surfaces throughout houses with the exception of the kitchen (fig. 1 ). as such, tirs is a rational vector control approach whereby ae. aegypti resting behavior guides targeted insecticide applications, thus reducing unnecessary exposure to chemicals for both applicators and household residents (fig. 1) , and also reducing the time it takes to spray a premise with no apparent loss in insecticidal efficacy [28] . in cairns, australia, an observational study found that tirs can reduce the probability of future denv transmission by 86-96% as compared to unsprayed premises [29] . concurrent trap collections of ae. aegypti in the heart of the outbreak showed that tirs was associated with a~70% reduction in gravid ae. aegypti female abundance [30] . in merida, mexico, a phase ii cluster randomized controlled trial (crct) evaluated the entomological impact of irs with bendiocarb (ficam®, bayer, a carbamate insecticide to which local ae. aegypti are fully susceptible) and reported reductions in indoor adult ae. aegypti abundance up to 70% over a 3-month period, compared to no reduction when the pyrethroid deltamethrin was used [31] . fitting such entomological information to an agent-based model of yucatan state, mexico, showed that high levels of tirs coverage (75% of houses treated once per year) applied preemptively before the typical dengue season (before july) could reduce denv infections by 89.7% in year 1 and 78.2% cumulatively over the first 5 years of an annual program [32] . such findings were confirmed with another modeling study comparing tirs with indoor space spraying in iquitos, peru [33] . these findings suggest that preemptive tirs may provide high short-term and long-term effectiveness in preventing abvs in endemic areas where transmission is seasonal. a systematic review has identified tirs as a highly promising approach for abv prevention [34] , but highlighted the limited evidence for tirs due to the absence of impact estimates from randomized controlled trials with epidemiological endpoints performed in endemic settings. the study protocol presented here introduces the design for a crct to test whether tirs, applied preventively, reduces laboratory-confirmed cases of abv illness and infection in the city of merida, yucatan state, mexico. trial endpoints are listed in table 1 and the approaches followed to quantify them will be described in subsequent sections. merida, the capital city of yucatan state, is the largest urban center in the region with 892,000 inhabitants [35] . the city has a tropical climate characterized by a mean annual temperature of 25.9°c and an annual fig. 1 targeted indoor residual spraying (tirs) to control ae. aegypti. in urban environments, houses are primarily built of brick and cement, and ae. aegypti rests preferentially below 1.5 m of height. spraying residual insecticides in walls below 1.5 m and in key resting sites such as under furniture (#1 in figure, represented in green) will eventually kill ae. aegypti that may be emerging from immature larval habitats outdoors (2) and rest indoors on treated surfaces (3) . after exposure to the residual insecticide, mortality can occur immediately (4) or after several hours/days (5) precipitation of 1050 mm. merida is endemic for abvs, with denv being persistently transmitted since 1979 and, more recently, co-circulating with chikv (since 2015) and zikv (since 2016) [36, 37] . abv transmission in merida is seasonal, beginning in july and peaking in october-november. baseline serological information (captured by elisa methods) on natural abv infection rates has been collected from merida in 2015-2016 through a school-based cohort that followed all family members living in the same household as the enrolled children [37] [38] [39] . in 2015, denv seroprevalence in the cohort was 70.2%, which increased with age from 31% in 0-8-year-olds to 79% in adults ≥ 20 years. in 2015-2016, the incidence of lab-confirmed abv illness in the cohort was 14.6 per 1000 person-years (95% ci 10.8, 19.2) [37] . the incidence of symptomatic dengue infections observed during the same period was 3.5 cases per 1000 person-years (95% ci 1.9, 5.9). the majority of seroconversions occurred in the younger age groups (≤ 14 years old) [37] [38] [39] . the incidence of symptomatic chikungunya illness was 8.6 per 1000 person-years (95% ci 5.8, 12.3) and the incidence rate of symptomatic zika illness was 2.3 per 1000 person-years (95% ci 0.9, 4.5) [37] . zika virus symptomatic attack rate in pregnant women from the cohort was 31% [40] . data from~40,000 geocoded denv, 2273 zikv and 1101 chikv symptomatic cases captured by mexico's national passive surveillance system from 2008 to 2016 identified denv transmission "hot-spots" in merida (areas with higher-than-average numbers of cases), which overlapped with chikv and zikv hot-spots [36] . combining these data with information from the cohort, we found that denv seroprevalence rates are~2× higher in hot-spot areas compared to other areas [36] . merida also has entomological laboratory infrastructure and trained personnel to conduct and evaluate tirs [28, 31] . the collaborative unit for entomological bioassays (ucbe) is a reference laboratory within the autonomous university of yucatan (uady) and is currently a world health organization good laboratory practice (glp) site for evaluating insecticide products for vector control [41] . the two-arm crct will include a total of 50 clusters of 5 × 5 city blocks each, with 25 clusters randomly allocated to the intervention (tirs) arm and 25 clusters allocated to the control arm (fig. 2) . routine ministry of health (moh) vector control actions performed in response to symptomatic abv cases reported to the healthcare system will not be interrupted and could occur across both study arms. upon detection of a suspected abv case in the national epidemiological database, yucatan moh mobilizes its staff aiming at containing local transmission by focusing efforts on adult mosquito control. truck-mounted ulv spraying with the organophosphate insecticides chlorpyrifos and malathion is widely implemented in merida, despite scientific evidence of its poor efficacy [34] . moh response also involves indoor space spraying (iss) with pyrethroids (mainly deltamethrin) and organophosphates (malathion) in houses that allow entry. limitations in personnel, geographic extent of outbreaks, and availability of resources (e.g., insecticides) commonly challenge moh operations, reducing the coverage and effectiveness of their actions [34] . all moh actions will be mapped and included in secondary analyses evaluating the impact of tirs in addition to routine vector control. participants in both arms will have access to any concomitant care they may choose to pursue, including cleaning their own yard and eliminating mosquito breeding habitats or using commercially available insecticide sprays or repellents (e.g., transfluthrin coils). clusters will be located within the areas previously identified as hot-spots of abv transmission [36] (fig. 2) . placing all clusters within areas of high abv incidence will increase power because of higher event rates and decrease the potential for imbalance across trial arms. to reduce contamination and edge effects, while all households in tirs clusters will be offered the intervention, epidemiological and entomological evaluations will occur in the center of each cluster, following a "fried egg" design ( fig. 2 ). entomological interventions that are constrained to a given area suffer from immigration of mosquitoes from untreated neighboring areas, as observed in a recent study that released wolbachia-infected mosquitoes in fresno, ca, and quantified mosquito dispersal up to 200 m from their release point [42] . by focusing participant enrollment on the central 3 × 3 blocks of the 5 × 5 clusters, we will minimize any contamination in our primary and secondary endpoints emerging from mosquitoes flying into treatment areas (fig. 2 ). this "fried egg" design is novel for vector-borne diseases and has been proposed as a rational approach to quantify the epidemiological impact of vector control [10] . to prevent selection bias, enrollment into the trial will occur in all clusters before tirs allocation has been determined. to assess power and sample size requirements, we analyzed historical passive surveillance data from the 192 hot-spot census tracts with population size of at least 1000 (from our previous work characterizing the abv hot-spot area [36] ). we used yearly data from 2008 to 2016 on the number of dengue, chikungunya, and zika cases recorded in children 0-14 years each year by census tract [36] . data were combined into pairs of adjacent years to mimic a 2-year trial period, and table 2 summarizes the mean incidence (number of cases over 2-year period/number of children) and intracluster correlation coefficient (icc) for a given 2-year period [43] . assuming 4% incidence over a 2-year period, 70% tirs efficacy, an icc of 0.035, and 20% loss to follow-up, we will require 92 age-eligible children enrolled per cluster for an overall sample size of 50 clusters and 4600 children to have 80% power to detect a significant reduction in abv incidence between arms (table 3) . clusters will be selected from the set of 190 census tracts within the abv hot-spot area [36] that have a total population size of at least 1000 and at least 300 children aged 0-14 years, per the 2010 census (fig. 2) . clusters are also selected to maximize the distance between the centroid of each cluster to the centroid of its nearest neighbor also in the trial. given a set of 50 clusters, covariate-constrained randomization [44] will be used to limit imbalance across trial arms with respect to the following census tract-level variables: population size, per 2010 census; population density, per 2010 census; percent employed population, per 2010 census; and cumulative number of abv cases between 2008 and 2016, per passive surveillance. these variables were selected because of their association with abv transmission risk. for each balancing factor, only allocation patterns where the mean value of clusters in group a divided by the mean value of clusters in group b is within 1/1.1 to 1.1 are retained. furthermore, we eliminate any allocation pattern with imbalance in the number of clusters per arm per sector greater than ± 1. to ensure randomization is not overly constrained, we only consider sets of 50 clusters that have many acceptable allocations into two groups of 25, satisfying validity criteria proposed by moulton [44] (e.g., pairs of clusters always or never appearing in the same arm). given the set of allocation patterns that meet the above balancing criteria, the biostatistics team at uf will use equal probability sampling to randomly select one allocation. a sample allocation pattern is plotted in fig. 2 . for participant enrollment, the study teams will be provided with a list of 50 census tracts for inclusion in the study, without a record of which census tracts are in group a or b. a random number generator produced by biostatisticians from uf will assign one group to tirs and one group to control. the trial will focus on the pediatric population, enrolling children aged 2-15 years in a longitudinal cohort to track their abv illness and lab-confirmed seroconversion over two (and potentially three) transmission seasons (fig. 2) . the previously conducted cohort study in merida indicated that the majority of dengue-naïve infections and seroconversions occurred in children ≤ 14 years old [37] [38] [39] . by following children aged 2-15 years at enrollment, we will capture the segment of the population with the highest probability of abv illness. we excluded younger children (< 2 years) because of the difficulties in obtaining blood specimens and potential for cross-reactivity with maternal antibodies [45] . there will be two levels of participation: at the household level and at the individual child level. table 4 shows the inclusion/exclusion criteria for each level. for each participation level, consent (and assent) will be obtained, as follows. on august 2020, after being given time to review information about the intervention, one adult household decision-maker will be asked for written consent to have their house included in the trial (at the time of consent, neither study personnel nor householders will know to which arm of the trial the house will be allocated). in consenting houses with children meeting the inclusion criteria (table 4) , individual consent/assent will be obtained during december 2020-january 2021. parental informed consent will be obtained for children aged 2-10 years, and both assent to participate from children and a parental informed consent will be obtained for 11-15-year-olds (additional file 2). enrollment of children will be focused in the central 3 × 3 city blocks of each cluster and will extend beyond if not enough children are enrolled in the core. consent will be obtained in participants' homes. study explanations will be provided to small groups of adults present in the household, whereas written consent and assent will be obtained from each individual participant. engaging communities early in the trial will be essential for maximizing participant acceptance and retention [46, 47] . an experienced team of 10 social workers, who will interact directly with study participants (through informal conversations, games, and other educational activities with children), will ensure they remain engaged throughout the duration of the study [47] . several factors may lead one household to withdraw from the intervention. householders may sell their home and move to a different location, and we will consider them lost to follow-up. householders may refuse to receive the intervention on a second or third opportunity, meaning they will not be subject to treatment (and therefore excluded from any future analysis). our team will document voluntary withdrawals and communicate them as part of the trial reporting. trial performance milestones table 5 shows our proposed milestones for the trial, following the spirit checklist, and sections below provide information on each step (see additional file 3). they can be divided into (a) trial planning, (b) tirs evaluation, and (c) trial analysis and reporting. trial design will be finished during the first year. enrollment is expected to last up to 3 months, when all 4600 children will enter follow-up. trial evaluation will occur for two transmission seasons, with the possibility of adding a third season should incidence of the primary endpoint be lower than assumed. trial analysis will include a projection of tirs impact, based on results from the crct, using our stochastic simulation model fitted to our study population. a baseline assessment of household characteristics (size, building materials, number of rooms, number of inhabitants) and ae. aegypti infestation and susceptibility to insecticides will occur july-december 2020 (fig. 2) . entomological collections will be conducted monthly in 10% of all houses located in the centers of the clusters (blue blocks in fig. 2 , equal to 1350 houses across 50 clusters). standard ovitraps will be placed to collect eggs that will be reared for assays to characterize insecticide susceptibility in mosquito populations. after the transmission season (january-april 2021) and during individual child enrollment, a baseline sero-survey will quantify levels of abv seroprevalence. all enrolled children will provide a blood sample by venipuncture, which will be tested for the presence of neutralizing antibodies against denv, chikv, or zikv (see laboratory methods below). personnel from the servicios de salud de yucatan (ssy; yucatan's ministry of health) will conduct the tirs after proper training [48] . based on our model [49] . we will prioritize the use of the organophosphate pirimiphosmethyl (actellic 300cs®), given its longer residual power in comparison to the carbamate bendiocarb (ficam®) [50] . however, if insecticide resistance profiles of mosquitoes after the first year of spraying show decreases in susceptibility to the active ingredient in actellic 300cs®, we will switch to ficam®. insecticide application will follow strict procedures developed by project team [48] . residents will be asked to temporarily leave the house during treatment and wait 1 h for the product to dry before re-entering. staff will wear branded uniforms with identification and use appropriate personal protective equipment. the epidemiological impact of tirs on the primary endpoint will be evaluated by active surveillance to detect and lab-confirm symptomatic denv, chikv, or zikv from july 1 to december 31 of each season (fig. 2) . enhanced symptomatic abv case detection will rely on three sources (fig. 3 ). ten field teams consisting of a nurse and a social scientist will conduct wellness visits to all enrolled children once per week, with the goal of identifying any probable case of abv illness. in addition to wellness visits, nurses will call parents/guardians of enrolled children regularly (twice per week) to check for the occurrence of any abv symptoms. when interacting with parents/guardians, nurses will also remind them that they can call our toll-free 01-800 number in case of any illness compatible with an abv infection. widely used by the previous cohort, the 01-800 number enhanced the detection of symptomatic individuals by providing study participants 24-7 access to a toll-free phone number to consult an "on call" project physician about any symptom in their children [37] . additionally, our project will access the online abv database managed by mexico's national center of preventive programs and diseases control (cenaprece) [51] to identify all reported symptomatic cases (including all ages, not only children) residing within study clusters in real time, and to map routine vector control actions performed by ssy. for ascertaining the primary endpoint, a suspected symptomatic abv case is defined as a participant with acute onset of fever (axillary temperature ≥ 38°c) or a non-focal rash plus any additional symptom such as headache, conjunctivitis, arthralgia, or myalgia. when a suspected abv case is identified through active surveillance, they will be visited preferably on the same day by one project physician to perform a physical examination (physical exam, temperature, vital signs). the doctor will be joined by one field team member, who will obtain demographic and behavioral data, and collect blood specimens. acute and convalescent (obtained 28 [range [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] days after symptom onset) blood specimens will be collected from each suspected case to confirm abv infection. additionally, history of movement (by a retrospective movement survey) [16, 52] will provide information on potential exposure locations for each case. after laboratory confirmation, participants will meet with study physicians, who will explain the diagnosis and potential steps if symptoms worsen. epidemiological impact will be further assessed via a secondary endpoint capturing serological evidence of abv infection (table 1) . yearly blood samples from all enrolled participants will be collected after the regular transmission season (from january to april) to test for serologic evidence of interval infection by denv, chikv, or zikv, as in [37] [38] [39] . in addition to collecting blood specimens, project team will also conduct annual prospective movement surveys to characterize the routine mobility patterns of participants. entomological impact will be measured by standardized monthly collections of indoor adult ae. aegypti (table 1) . a random sample of 10% of the houses located in the center ("yolk" of our fried egg design) of each cluster (~1350 houses in total) will be visited and surveyed for the presence of adult ae. aegypti mosquitoes indoors using prokopack® aspirator collections performed for 10 min per house, as described in [31, 53] . female ae. aegypti collected indoors will be pooled by city block and tested for abv infection. entomological surveys will begin immediately following tirs implementation (july 1) and will be performed monthly for 6 months (until dec 31). monthly who cone bioassays [31, 54] will be done in a random sample of 25 treated houses to monitor the residual efficacy of the insecticide used. venipuncture procedures will be performed using standard aseptic techniques. an experienced phlebotomist will take the blood sample from an antecubital vein. blood will be collected into vacutainer® collection tubes or by a needle and syringe. a 22-gauge needle will be used for 5-15-year-olds, and a 23-gauge needle for children < 5 years. blood specimens will be immediately taken to yucatan state diagnostics laboratory, dependent of the ministry of health for immediate molecular diagnostics (acute samples) or serum separation, followed by elisa tests (convalescent samples and annual blood draws). aliquots of all specimens will be stored at − 70°c in labeled polypropylene cryogenic vials at uady, and then transported to emory university for advanced diagnostics. long-term specimen storage will occur at emory university. specimens from individuals who did not sign the "future use" clause of the consent will be discarded after diagnostics, following sample processing procedures established by yucatan state laboratory. figure 4 shows all lab testing components of the trial, which will occur at ssy, uady and emory university. acute samples from active surveillance will be tested at the yucatan state laboratory using a multiplex reverse transcriptase-polymerase chain reaction (rt-pcr) [55] and virus-specific igm elisas. annual serologic samples will be tested at yucatan state laboratory by antigen capture elisa for human igg [56] , and positive samples will be taken to emory university for focus reduction neutralization testing (frnt) [57] [58] [59] . natural abv infection rates in ae. aegypti will be detected by rt-pcr [55] at uady. standard cdc bottle bioassays [60] will assess phenotypic resistance of adult ae. aegypti from treatment and control clusters pre-intervention and at 3 and 9 months post-intervention every year. f0, or f1 progeny, from field-collected eggs will be screened for susceptibility to pirimiphos-methyl [60] . if resistance is detected, both dna and rna will be analyzed from a subset of the phenotyped mosquitoes to calculate the frequencies of known resistance alleles as well as expression of resistance-associated genes. given cross-reactivity and variable sensitivity of assay methods, we will use a composite approach to diagnose abv infections (fig. 4) . for active surveillance, two diagnoses are used: preliminary diagnosis-suspected cases are confirmed if rt-pcr is positive for any abv. if rt-pcr is negative, the acute specimen igm result is considered and any positive igm result indicates a preliminary diagnosis of abv infection. if both zikv and denv igm assays are positive, the case is designated as a case of flavivirus infection. final diagnosis-paired acute and convalescent specimens will be tested for igm and igg seroconversion. these results will refine the case designation. a case with laboratory evidence of abv infection in the acute testing must also demonstrate seroconversion or increasing levels of igg or igm in the convalescent specimen. rt-pcr+ suspected cases that do not exhibit seroconversion or increase in igg or igm levels will be designated recent infections, but not abv cases (that is, this result is most consistent with an etiology other than abv infection as the cause of the symptomatic illness). additionally, igg or igm seroconversion or increasing igg that is observed when rt-pcr and acute specimen igm are negative will be considered confirmation of an abv case. this approach may increase the sensitivity to detect abv cases that have false negative pcr testing and have not yet mounted an igm response at the time of presentation. finally, if convalescent serology does not distinguish between denv and zikv infection, the annual surveillance sample for that subject will be considered. if it is clear from neutralization testing on the annual surveillance specimen what the intervening viral infection was, that will become the designation of the abv case captured during active surveillance. the annual serologic surveillance takes into account that the majority of abv infections are inapparent. it will also account for the known cross-reactivity among abvs. chikv is an alphavirus, and serologic assays for chikv perform with high sensitivity and specificity. elisa is likely sufficient for annual chikv serosurveillance. denv and zikv are related flaviviruses, and conventional approaches to serologic diagnosis of flavivirus cases can exhibit reduced specificity. however, the antibody response to denv and zikv is dynamic, and cross-reactive antibody levels are greatest in the first few months after infection. thus, cross-reactivity is present but less intense in late convalescence, which is one reason for performing serosurveillance in the lowtransmission season. for flavivirus surveillance, neutralizing antibody titers will be compared using the frnt50 (inverse of serum dilution that exhibits 50% of maximum neutralization). conversion of neutralization assays from negative to positive in subsequent years is strongly supportive of interval infection. the precise infecting virus (denv1-4 serotype or zikv) can often be identified by comparing relative frnt50 values for each virus. a ≥ 4-fold difference in the frnt50 is considered a significant difference. once an individual has high titers to multiple denv serotypes, detection of additional denv infection is challenging by serosurveillance alone. the details of interpreting all possible flavivirus neutralizing antibody profiles are beyond the scope of the article. we have reviewed the key concepts recently [61] . the primary analysis will estimate the overall efficacy of tirs in reducing the rate of laboratory-confirmed abv illness, where the overall efficacy is estimated as one minus the hazard ratio from a cox proportional hazards model [62] . the hypothesis test for the primary outcome will be a score test of the null hypothesis that tirs efficacy is 0; the two-sided test will be conducted at the α = 0.05 level. the cox proportional hazards model will be fit using individual-level data for eligible and consenting children. the primary endpoint will be time to symptom onset of first laboratory-confirmed abd. the time origin will be july 1 prior to the first season, by which time spraying will have been completed. the analysis will consider events occurring between july 1 and december 31 of each year of the study, as this corresponds to the time when the residual effect of the insecticides used in tirs is expected to be active and while active surveillance is ongoing. to account for clustering, the model will include a robust variance estimator with two parameters; one characterizes the level of correlation in outcomes between children within the same household, and one characterizes the level of correlation in outcomes between children in different households but within the same cluster. we will use schoenfeld residuals to assess departures from proportionality, as would occur if the effect of tirs varies over time [63] . we will use timedependent (piecewise) models where significant nonproportionality occurs [64] . planned secondary analyses of clinical and human serological data include: cox proportional hazards model with time to first laboratory-confirmed symptomatic abv disease as the endpoint, adjusting for additional cluster-and household-level covariates (e.g., population density, household size, socio-economic status). cox proportional hazards model with time to first laboratory-confirmed symptomatic abv disease as the endpoint, adjusting for routine human movement as measured by the prospective movement survey (measured in all enrolled participants). the proportion of time in treated areas will be included as a further covariate, as described in [10] . disease-specific versions of the primary analysis (e.g., time to first laboratory-confirmed symptomatic dengue disease as the endpoint), if data permit. analysis of recent human movement measured by a retrospective movement survey in enrolled participants presenting with symptoms for laboratory confirmation. the data will be analyzed using a test negative design-type structure, where individuals testing negative for any abv will serve as a comparator group for individuals testing positive for abv. the analysis will adopt recently developed methods for cluster randomized vector control trials [65, 66] . binomial generalized linear mixed effects model to assess the efficacy of tirs for reducing laboratoryconfirmed denv, chikv, or zikv infection will be analyzed as cumulative incidence over the two (or potentially three) transmission seasons, as measured from annual serological samples. given the larger number of sub-clinical and undetected abv infections compared to symptomatic abv illness, the study will be amply powered to detect a statistical difference in abv infections (measured by annual serology). using the passive surveillance data, we will quantify the community impact of tirs on symptomatic abv cases reported to the public health system, beyond our pediatric cohort. poisson regression will be used to compare cluster-level incidence rates across trial arms. acceptability of tirs intervention will be assessed by calculating summary statistics from the postintervention data. acceptability measures will be paired with any adverse reactions experienced or reported by study participants and assessed by our team of physicians. for mosquito data, planned secondary analyses include: the following ae. aegypti adult indices will be calculated for each sampling date and compared between treatments and over time: presence (binomial variable) and abundance (count variable) of adults, females, and blood-fed females per house. generalized linear mixed effects models (glmm) nested at the cluster (level 1) and city block (level 2) levels will be used to compare each entomological index between treatment and control arms, as in [31] . link functions for glmms will be binomial for presence indices and negative binomial for abundance indices. the best fit models (after comparing aic values for models including all levels or only level 1) will be used to calculate odds ratios (or; for mosquito presence/absence) and incidence rate ratios (irr; for mosquito abundance) using control houses as the unit of comparison. we will calculate the operational efficacy of the intervention as e = (1 − irr) × 100. this measure, ranging between 0 and 100, describes the percent reduction of mosquito abundance in treated houses with respect to the control. similarly, a negative binomial glmm will test for differences in treatment and control arms for infection rates with denv, chikv, or zikv, calculated as minimum infection rate, following similar statistical methods as for ae. aegypti abundance. epidemiological and entomological information will be combined to quantify the relative reduction in the incidence of symptomatic abv illness at the cluster level observed from a measured entomological reduction due to tirs (measured as number of adult or female ae. aegypti). binomial glmms, with random intercepts at the cluster and year levels, will quantify the association between both variables for the duration of the trial and provide values of threshold vector densities associated with a significant reduction in the odds of human symptomatic infection. transmission modeling our existing mathematical model for yucatan [32, 67, 68] will simulate the effectiveness of tirs for different scenarios of intervention coverage and insecticide residual power, using the observed trial data as a critical model input. this agent-based model of individual people and mosquitoes incorporates household demography, a spatially heterogeneous population structure based on census and remote sensing data, movement of workers and students, and seasonal fluctuations in mosquito population and incubation period. different movement (e.g., mosquito vs. human) and transmission (e.g., pathogen introduction and elimination) dynamics become relevant at different spatial scales; thus, we will predict the impact of scaling up tirs to the entire state rather than treating just merida. simulating epidemiological trends of scaled-up tirs for periods longer than the duration of this trial (e.g., a decade) will evaluate the effect of changing population-level immunity and generate measures of effectiveness that are more informative for programmatic decision making. emory university will coordinate all aspects related to data storage, management, and sharing. a data management core (dmc) provides timely and efficient curation and dissemination of study data from multiple sources (e.g., clinical, laboratory, passive surveillance, entomology, demographic, ministry of health interventions), all essential to the success of the trial (fig. 5) . information from the trial including consent forms, surveys, active surveillance forms, laboratory diagnostics, entomological surveys, mobility surveys, withdrawal forms, intervention acceptability, and annual blood draws will be collected in paper form and digitally recorded into our redcap database (see below) by the data entry staff at uady. staff will enter information in a private dedicated space at uady-ucbe. laboratory results at emory university will be entered directly into the redcap database by laboratory staff using an online form. all forms were developed by our team specifically for this study. all data will be stored on secure data servers and kept strictly confidential (with participant identifiers blinded by using non-identifiable ids). households are assigned codes unique to the project database, which are then used to identify all subsequent data we will collect. outside of the database, these codes will not be interpretable, rendering the data effectively unidentifiable without access to our servers. blinding of identifiable data will occur in the analysis stage also. all diagnostics of specimens will be conducted using the sample id, blinding laboratory personnel from any identifiable information or membership of samples to a given study arm. access to the database will be primarily administered through a custom, web-based interface with restricted access privileges and encrypted data transfer (redcap, https://www.project-redcap.org/). different data entry interfaces will be generated for each component. access will be limited to certified project personnel and certified associates, who will be provided unique login and password combinations. database servers will be protected by multiple layers of security. databases will be shared electronically through secure servers among key project personnel for analyses, publications, oral presentations, and project development. regular checks of the database for completeness and accuracy will be performed. the heterogeneous nature of abv transmission may dictate the need for a third transmission season to evaluate the epidemiological impact of tirs. the decision to continue into a third season will follow an event-driven decision process. after the second season evaluating tirs, the statistical team will quantify the number of total primary endpoints. we will pursue the following ranking in order to evaluate whether to stop or continue into a third season: the choice of < 20 endpoints represents the target number of events needed for a power of 80% when tirs efficacy is 90%. overall, the risks to study participants are minimal in all of our study procedures ( table 6 ). the most serious risk is related to potential intoxication with the insecticides used in tirs (table 6 ). both actellic 300cs® and ficam® have been approved by the world health organization (who) for indoor control of mosquitoes [18, 19] . the who's hazard assessments concluded that, when used for indoor residual spraying as instructed and at the recommended doses, both products do not pose undue hazards to the spray operators or residents of the treated dwellings [69] [70] [71] . provided that operational guidelines are followed, routine cholinesterase monitoring of spraying personnel during indoor residual spraying programs is not required [69] [70] [71] . during the period of active surveillance, immediately after tirs application, study participants will be contacted regularly (1×/week in-house or 2×/week by phone calls) by our team, who will ask for the presence of any sign of intoxication in any of the members of the house. such contacts will coincide with the epidemiological evaluation of the intervention. in addition to our team's direct contact, households receiving tirs will receive a pamphlet with a 0-1800 toll-free number for them to self-report any signs of intoxication. once in the presence of a probable case of intoxication, a physician will medically assess the patients to diagnose the extent of their condition. vital signs, together with respiratory distress (i.e., bronchorrhea, bronchospasm) and clinical evidence of cholinergic excess (i.e., salivation, vomiting, urination, defecation, miosis), will be followed until they resume. in cases of severe intoxication, plasma cholinesterase activities will be assessed, together with electrolytes and serum lipase (both tests can be performed at uady's school of medicine public health laboratory, which routinely performs such tests for pesticide occupational exposure assessments). given the insecticide dose and mode of application used in tirs, we expect most intoxications to be mild and resume after exposure ends (i.e., after individuals are exit their home). our preliminary results from our phase ii entomological trial utilizing actellic 300cs showed that in 160 houses (including 630 individuals) a total of 19 cases (3%) of symptoms compatible with a reaction to the insecticide were detected (vazquez-prokopec et al. unpublished). the most common signs (accounting for 85% of symptoms) were headache, nausea, and mild skin irritation. however, if the physician considers that a moderate to severe intoxication occurred, serological tests will be performed to confirm the cause of their condition. all probable aes will be noted in the adverse event log (ael), which will be the primary form of communication between physicians and the pi. aels will be filed immediately (one record per event) after the detection of a probable ae (the form will include links to any specific medical record or laboratory record associated with each case). once an ael is filed in the database, the pi will receive an alert requiring his attention. upon conversation with the study doctors, the pi will make an informed decision as to whether the condition represents a reportable ae or not. any ae or unanticipated problems (up; serious, life threatening, or result in death and unexpected and caused by the intervention) involving risk to participants will be notified to the irb within 10 calendar days of their occurrence. emory irb will generate specific forms within their eirb platform to report any aes or ups associated with this study. the irb reports on aes or ups will be received by the nih program officer assigned to this study. in the unlikely situation that ups emerged due to tirs implementation, emory irb and the nih program officer will coordinate with the pi about the temporary or permanent suspension of this study. this project will strengthen a unique us-mexico partnership involving universities and research centers (emory, uady, fred hutch, uf) and federal agencies (cenaprece, mexico's national institute of public health, cdc) together with state agencies (ssy). emory university will lead the project and will be in charge of overall coordination, procurement of commodities (e.g., insecticides, diagnostic reagents), and data coordination, advanced diagnostics, and irb approval. the autonomous university of yucatan will coordinate all aspects of the field implementation of the trial as well as the integration of field and laboratory data streams. trial design will be led by fred hutchinson cancer research center. analyses for the primary and secondary endpoints as well as for evaluation of trial continuation will be conducted by uf (ira longini, natalie dean), with input from biostatisticians from fred hutchinson cancer research center. uf will also lead the mathematical modeling component. technical support will be provided by the us cdc to evaluate patterns of insecticide resistance in space and time. mexico's cenaprece will provide access to the online abv database. the ssy will contribute spraying personnel and access to samples for laboratory testing in support of the trial's active surveillance procedures, as well as help with communication about tirs and the trial's goals. dr. silvina contreras-capetillo, md (hospital o'horan, merida, mexico), expert in clinical aspects of aedes viruses, particularly genetic malformations in zika, will act as an independent trial monitor. the funder (nih) considered the data gathered in this project will be identifiable and certain data types, such as movement interview, are sensitive. the primary risks lie with identifying the individuals who provided information they consider confidential (e.g., movement to private locations). there is a small risk that the repeated blood collections will cause or exacerbate anemia. in-depth interviews (prospective and retrospective movement interviews) risks to study participants are minimal. participants may feel that in-depth interviews take up too much time-but they have the option of ending their participation at any time. there are no sensitive topics covered, but if any participant feels that there is something he/she does not want to talk about, he/she does not need to answer all questions. the low risks associated with the intervention not to merit the establishment of a dsmb. as such, the study team and the nih program officer(s) will communicate directly about study findings, reports from independent trial monitor, continuation rules, and adverse events. any deviation from protocol will require prior approval by the nih program officer. the study protocol and associated documents including informed consent forms are approved by the respective institutional review boards (irb) of all collaborating institutions as well the national institutes of health. the trial protocol was registered on clinicaltrials.gov (nct04343521) on april 13, 2020. it will be made clear during the consent process that no information can be shared with anyone other than designated study personnel, the paper and computer files will be well protected, and we will ask that interviews be carried out one-on-one to prevent other family members listening in. consent and assent forms include a separate section where participants give permission to the pi to keep their specimens for future tests or studies. we will take all necessary measures to ensure confidentiality. it will also be made clear to study personnel that any violation of confidentiality would be a fireable offense. all paper data forms will be stored in locked files or cabinets in uady in a specified storage facility with limited access. access to computer data files will be password protected to allow exclusive access to appropriate study personnel. the paper data forms associated with the project (e.g., consent forms, questionnaires, census) will be stored in accordance with irb regulations. should consent be given for future use, then serological samples will be stored indefinitely. the samples will not have any participant identifiers, beyond the participant's code. if, however, consent for future use is not given, the blood samples will be destroyed immediately (using strict protocols at uady for disposal of biological samples) following completion of the project. monitor evaluations will occur once a year and will be timed to occur right after the epidemiological evaluation of tirs (january-march). on every visit, dr. contreras-capetillo will file a monitoring log and a self-monitoring tool form. selfmonitoring will be performed on a random selection of 10% of study participants. the monitor will also review records of all adverse events as well as the information of any dropouts that occurred between monitoring periods. after the visit, the monitor will submit the self-monitoring tool to the pi, together with any recommendations based on the visit. a phone call between the monitor and the pi will be scheduled, should corrective actions be required. novel tools and strategies that are operationally feasible and widely scalable are desperately needed to prevent and control abvs. this phase iii crct trial will quantify the epidemiological impact of tirs in preventing abvs and generate a definitive evidence base for assessing the public health value of this approach. the heavy reliance on pyrethroid insecticides for mosquito control has led to widespread pyrethroid resistance on a global scale [72] . the high levels of resistance to pyrethroids found in mexico [73] , including the yucatan [49] , prompted cenaprece to expand the chemical groups used for aedes control to other insecticide classes such as carbamates and organophosphates, to which local ae. aegypti are susceptible [49, 73] . a recent entomological crct performed in merida, yucatan, demonstrated that utilizing an insecticide to which ae. aegypti were susceptible had a significant impact on indoor mosquito density, as compared to the use of a pyrethroid to which the local population was resistant [31] . the selection of new insecticide formulations (e.g., microencapsulated insecticides) with longer residual power (ca. 5-7 months) can further increase the effectiveness of tirs. fortunately, r&d for new insecticide formulations as well as novel chemistries for vector control has expanded, and new products are at various stages in product development pipelines [74] . findings from this trial will not only aid in understanding how residual insecticides can function effectively for abv control but also help catalyze r&d for residual insecticide formulations better suited for the surfaces and materials found in urban areas. responding only to symptomatic abv cases likely misses a significant number of cases as a large proportion of abv infections are asymptomatic, which can still successfully infect mosquitoes [75] and in turn significantly contribute to abv transmission [17] . findings from a spatially explicit agent-based model of dengue dynamics in yucatan, mexico [32, 67, 68] , suggested that tirs maximal effectiveness occurs when it is deployed preemptively (before the seasonal peak of abv transmission) rather than reactively. our trial will evaluate the preemptive implementation of tirs (spraying 1-2 months prior to the beginning of the peak abv transmission season). if found efficacious, the trial will make a strong case for the public health value of preemptive, long-lasting vector control measures against abvs. this finding would contribute to a paradigm shift in aedes control and abv prevention, leading to innovations in the way that interventions are conceptualized and brought to scale in operational settings. while the crct approach itself is largely standard, focusing on adherence to core epidemiological principles [76] , our trial will incorporate several innovative features into the randomization and analysis. we have modified the covariate-constrained randomization procedure [44] to include a selection step to maximize the geographical spread of the clusters. this strategy may be useful in future vector control trials. through the use of highly spatially resolved prospective and retrospective movement surveys, we will be able to refine our estimates of tirs efficacy to account for participant time spent in treated and untreated areas [10] . finally, we are able to directly integrate trial data on mosquito abundance, human movement, and clinical outcomes into an existing mathematical model to better understand the potential population-level impacts of tirs. using statistical simulations to help interpret and contextualize the results of an infectious disease trial is an emerging area of research [77] . to fulfill the critical need for carefully designed trials for vector control [15] , this study will provide key data on the epidemiological impact of tirs on abvs and contribute methodologies and approaches for the design of future crcts. at the time of submission, the project is on its second trimester (table 5 ) and main administrative activities have been activated. initial community contacts are expected to occur on mid-october 2020, with concurrent participant enrollment (level 2) and baseline serology occurring january-march 2021. such timeline differs 3 months from the original proposed plan, due to the covid-19 contingency that has limited presence of field personnel accessing households. protocol version 2.0: july 14, 2019 (approved on august 1, 2019, by nih/niaid/dmid and on november 12, 2019, by emory university irb). urbanization and globalization: the unholy trinity of the 21(st) century zika virus global expansion of chikungunya virus: mapping the 64-year history the global distribution and burden of dengue global spread of dengue virus types: mapping the 70 year history economic and disease burden of dengue in mexico an estimate of the global health care and lost productivity costs of dengue. vector borne zoonotic dis after the epidemic: zika virus projections for latin america and the caribbean cost-effectiveness of increasing access to contraception during the zika virus outbreak quantifying the epidemiological impact of vector control on dengue unforeseen costs of cutting mosquito surveillance budgets dengue and dengue hemorrhagic fever a critical assessment of vector control for dengue prevention is dengue vector control deficient in effectiveness or evidence?: systematic review and meta-analysis evidence-based vector control? improving the quality of vector control trials houseto-house human movement drives dengue virus transmission contributions from the silent majority dominate dengue virus transmission world health organization. guidelines for testing mosquito adulticides for indoor residual spraying and treatment of mosquito nets world health organization. indoor residual spraying. an operational manual for indoor residual spraying (irs) for malaria transmission control and elimination. geneva: world health organization world health organization. application of residual sprays for vector control world health organization. pesticides and their application for the control of vectors and pests of public health importance an investigation of the house-frequenting habits of mosquitoes of the british guiana coastland in relation to the use of ddt eradication of aedes aegypti on cayman brac and little cayman, west indies, with abate (temephos) in 1970-1971 determinants of heterogeneous blood feeding patterns by aedes aegypti in iquitos behavior of resting aedes aegypti (culicidae: diptera) and its relation to ultra-low volume adulticide efficacy in panama city, panama indoor resting behavior of aedes aegypti (diptera: culicidae) in a new, cost-effective, battery-powered aspirator for adult mosquito collections efficacy of novel indoor residual spraying methods targeting pyrethroid-resistant aedes aegypti combining contact tracing with targeted indoor residual spraying significantly reduces dengue transmission entomological investigations in a focus of dengue transmission in cairns, queensland, australia, by using the sticky ovitraps deltamethrin resistance in aedes aegypti results in treatment failure in merida forecasting the effectiveness of indoor residual spraying for reducing dengue burden optimizing the deployment of ultra-low volume and indoor residual spraying for dengue outbreak response community effectiveness of indoor spraying as a dengue vector control method: a systematic review principales resultados de la encuesta intercensal 2015: yucatán. available spatio-temporal coherence of dengue, chikungunya and zika outbreaks in merida epidemiology of dengue and other arboviruses in a cohort of school children and their families in yucatan, mexico: baseline and first year follow-up dengue seroprevalence in a cohort of schoolchildren and their siblings in yucatan seroprevalence of dengue antibodies in three urban settings in yucatan, mexico zika virus infection in pregnant women of yucatan efficient production of male wolbachia-infected aedes aegypti mosquitoes enables large-scale suppression of wild populations estimating intraclass correlation for binary data covariate-based constrained randomization of grouprandomized trials decay and persistence of maternal dengue antibodies among infants in bangkok what makes community engagement effective?: lessons from the eliminate dengue program in queensland australia studying sociocultural factors associated with dengue fever in elementary school children in yucatán, mexico. sage research methods cases pan american health organization. manual for indoor residual spraying in urban areas for aedes aegypti control. washington: pan american health organization spatial variation of insecticide resistance in the dengue vector aedes aegypti presents unique vector control challenges bioefficacy of two nonpyrethroid insecticides for targeted indoor residual spraying against pyrethroid-resistant aedes aegypti nation-wide, webbased, geographic information system for the integrated surveillance and control of dengue fever in mexico strengths and weaknesses of global positioning system (gps) data-loggers and semi-structured interviews for capturing fine-scale human mobility: findings from iquitos multi-scale analysis of the associations among egg, larval and pupal surveys and the presence and abundance of adult female aedes aegypti (stegomyia aegypti) in the city of merida the impact of indoor residual spraying of deltamethrin on dengue vector populations in the peruvian amazon performance of the trioplex real-time rt-pcr assay for detection of zika, dengue, and chikungunya viruses detection of anti-arboviral immunoglobulin g by using a monoclonal antibody-based capture enzyme-linked immunosorbent assay guidelines for plaque-reduction neutralization testing of human antibodies to dengue viruses in-depth analysis of the antibody response of individuals exposed to primary dengue virus infection comparison of plaque-and flow cytometry-based methods for measuring dengue virus neutralization guideline for evaluating insecticide resistance in vectors using the cdc bottle bioassay serologic tools and strategies to support intervention trials to combat zika virus infection and disease design and analysis of vaccine studies partial residuals for the proportional hazards regression model time-dependent covariates in the cox-proportional-hazards regression model cluster-randomized testnegative design trials: a novel and efficient method to assess the efficacy of community-level dengue interventions analysis of clusterrandomized test-negative designs: cluster-level methods projected impact of dengue vaccination in yucatan designing effective control of dengue with combined interventions pdf; jsessionid=475c259cf76368ee2afd337d429e37c0?sequence=1 insecticides approved for indoor residual spraying contemporary status of insecticide resistance in the major aedes vectors of arboviruses infecting humans insecticide susceptibility status in mexican populations of stegomyia aegypti (= aedes aegypti): a nationwide assessment disruptive technology for vector control: the innovative vector control consortium and the us military join forces to explore transformative insecticide application technology for mosquito control programmes asymptomatic humans transmit dengue virus to mosquitoes cluster randomised trials simulations for designing and interpreting intervention trials in infectious diseases springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors acknowledge scott ritchie for his inspiring contribution to the development of the tirs methodology. drs. michael dunbar, gregor devine, richard reithinger, gabriela gonzalez-olvera, wilbert bibiano-marin, and amy crisp provided feedback for the design or conceptualization of the trial. the findings and conclusions in this paper are those of the authors and do not necessarily represent the official position of the centers for disease control and prevention or the national institutes of health. supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04780-7. the full trial protocol will be made publicly available within 1 year of the conclusion of data collection. the datasets generated in this study will be made available by the corresponding author on reasonable request, within 1 year of the conclusion of data collection. this trial protocol has been approved by emory university (irb00108666) and the autonomous university of yucatan (cei-05-2020) and endorsed by the secretarias de salud de yucatan. written consent/assent will be obtained from participants and kept in a secure place for record-keeping and trial monitor evaluation. the authors declare that they have no competing interests.author details 1 unidad colaborativa de bioensayos entomológicos, campus de ciencias biológicas y agropecuarias, universidad autónoma de yucatán, merida, key: cord-311697-2w9qody4 authors: liu, xi; chen, huili; shang, yuqi; zhu, hongqiong; chen, gongqi; chen, yuanli; liu, shaoxuan; zhou, yaoyong; huang, mingxing; hong, zhongsi; xia, jinyu title: efficacy of chloroquine versus lopinavir/ritonavir in mild/general covid-19 infection: a prospective, open-label, multicenter, randomized controlled clinical study date: 2020-07-08 journal: trials doi: 10.1186/s13063-020-04478-w sha: doc_id: 311697 cord_uid: 2w9qody4 background: the outbreak of covid-19 (caused by sars-cov-2) is very serious, and no effective antiviral treatment has yet been confirmed. the adage “old drug, new trick” in this context may suggest the important therapeutic potential of existing drugs. we found that the lopinavir/ritonavir treatment recommended in the fifth edition of the treatment plan of china can only help to improve a minority of throat-swab nucleic-acid results (3/15) in hospitals. our previous use of chloroquine to treat patients with covid-19 infection showed an improvement in more throat-swab nucleic-acid results (5/10) than the use of lopinavir/ritonavir. methods/design: this is a prospective, open-label, randomized controlled, multicenter clinical study. the study consists of three phases: a screening period, a treatment period of no more than 10 days, and a follow-up period for each participant. participants with covid-19 infection who are eligible for selection for the study will be randomly allocated to the trial group or the control group. the control group will be given lopinavir/ritonavir treatment for no more than 10 days. the trial group will be given chloroquine phosphate treatment for no more than 10 days. the primary outcome is the clinical recovery time at no more than 28 days after the completion of therapy and follow-up. the secondary outcomes include the rate of treatment success after the completion of therapy and follow-up, the time of treatment success after no more than 28 days, the rate of serious adverse events during the completion of therapy and follow-up, and the time to return to normal temperature (calculated from the onset of illness) during the completion of therapy and follow-up. comparisons will be performed using two-sided tests with a statistical significance level of 5%. discussion: this experiment should reveal the efficacy and safety of using chloroquine versus lopinavir/ritonavir for patients with mild/general covid-19 infection. if the new treatment including chloroquine shows a higher rate of throat-swab sars-cov-2 real-time fluorescent reverse transcription polymerase chain reaction (rt-pcr) negativity and is safe, it could be tested as a future covid-19 treatment. trial registration: chinese clinical trial registry, id: chictr2000029741. registered on 11 february 2020. in december 2019, patients with unexplained pneumonia appeared in wuhan, china, and were subsequently identified as a having a novel type of coronavirus. on 30 january 2020, the world health organization named it "covid-19 (corona virus disease-2019, caused by severe acute respiratory syndrome corona virus (sars-cov-2))." the covid-19 epidemic is now spreading throughout the world. coronavirus is a single-stranded, positive-strand rna (ribonucleic acid) virus with an envelope [1] . there are currently no clinically specific drugs for hcovs (human corona viruses). recently, the national health commission of china announced a new coronavirus-infectionrelated pneumonia diagnosis and treatment program (the fifth edition, url: http://www.nhc.gov.cn/yzygj/s7653p/2 02002/3b09b894ac9b4204a79db5b8912d4440/files/72603 01a393845fc87fcf6dd52965ecb.pdf), which proposed the trial of lopinavir/ritonavir for its antivirus effect [2] [3] [4] . our previous use of this drug combination found that the effect of lopinavir/ritonavir on covid-19 was unsatisfactory, as it only helps to improve the minority of throatswab nucleic-acid results (3/15) . chloroquine is not only used as an antimalarial drug, but is also used for the treatment of autoimmune diseases due to its immunomodulatory activity [5] . previous studies have shown that chloroquine exerts antiviral effects through the following mechanisms: 1. it can change the ph of acidic organelles [6] (such as endosomes), so inhibits infections such as borna disease virus [7] , avian leukemia virus [8] , and zika virus [9] 2. it can change the glycosylation pattern of the hiv virus gp120 envelope, which inhibits the replication of hiv (human immunodeficiency virus) virus in cd4 + t cells [10] 3. it can effectively inhibit autophagy in the lungs of avian influenza h5n1 mice and reduce the damage to the alveolar epithelium [11] 4. it inhibits viral replication by blocking the autophagy phenomenon induced by the zika virus, and can cut off vertical infection of the zika virus from the maternal-fetal pathway [12] multiple studies have found that chloroquine has anti-sars-cov activity: 1. chloroquine can inhibit viral replication by reducing the terminal glycosylation of the angiotensin-converting enzyme 2 (ace2) receptor on vero e6 cells and interfering with the binding of sars-cov to the ace2 receptor [13, 14] 2. chloroquine inhibits the replication of hcov-229e (and sars-cov, both belong to the αgroup hcovs) by inhibiting the activation of p38 mitogen-activated protein kinase (mapk) in the l132 human embryonic-lung-cell line [15] 3. the spike protein (s protein) of sars-cov-2 is similar in structure to that of sars-cov, and can bind to the ace2 receptor on the host-cell surface to infect the host epithelial cells [16] 4. remdesivir (gs-5734) and chloroquine (sigma-c6628) can effectively inhibit sars-cov-2 infection [17] this study will compare the efficacy, safety, and impact on patient compliance between the chloroquine phosphate regimen with the lopinavir/ritonavir regimen in mild/general covid-19 infection. setting this randomized controlled trial is to be conducted at the fifth affiliated hospital of sun yat-sen university, the ninth people's hospital of dongguan, zhongshan second people's hospital, and jiangmen central hospital. these hospitals are located in guangdong, china. the clinical research flowchart (crf) of the research process is shown in fig. 1 . once the volunteered participants have been included, researchers will explain the research procedures in detail and require them to sign a written informed consent form which is signed by the subjects or their legal representative. all participants can withdraw their consent at any time during the trial. this is a prospective, open-label, randomized controlled, multicenter clinical study with two arms. eligible patients are first screened by safety laboratory testing. patients with diagnosed mild/general covid-19 infection are randomized to the following two arms at a 1:1 ratio: 1. arm 1 (control arm): lopinavir/ritonavir treatment for diagnosed mild/general covid-19 infection uses lopinavir 800 mg/day and ritonavir 200 mg/day for no more than 10 days 2. arm 2 (investigation arm): chloroquine phosphate treatment using chloroquine phosphate 1000 mg/ day, equivalent to chloroquine 600 mg/day for no more than 10 days the crf is shown in fig. 1 . the schedule of treatment visits and data collection (also known as the crf) is shown in table 1 . researchers will evaluate treatment adherence during each visit. if a scheduled visit is delayed or cancelled, the research team will contact the participant at once. no treatment or intervention is prohibited for any of the participants. the primary outcome is the clinical recovery time of no more than 28 days after the completion of therapy and follow-up. the secondary outcomes include the rate of treatment success after the completion of therapy and follow-up, the time of treatment success after no more than 28 days, the rate of serious adverse events (saes) during the completion of therapy and follow-up, and the time to return to normal temperature (calculated from the onset of illness) during the completion of therapy and follow-up. we define the clinical recovery time as the time (in hours, no more than 28 days) from the start of study drug intervention to normalization of body temperature, respiratory symptoms (cough, nasal stuffiness, nasal discharge, etc.), respiratory frequency, and blood-oxygen saturation. specifically, also meeting the following criteria at the same time: ① no fever: axillary body temperature ≤ 37.2°c ② relief of respiratory symptoms (72 consecutive hours) ③ respiration rate ≤ 24/min (resting state) table 1 the schedule of treatments and data collection the sofa (sequential organ failure assessment) score predicts mortality risk for patients in the intensive care unit based on laboratory results and clinical data 1 adverse events (aes) refer to adverse medical events that occur after a patient or clinical trial participant receives a drug, but they are not necessarily causally related to treatment. serious adverse events (saes) refer to events that require hospitalization, prolonged hospital stay, disability, affect working ability, are life-threatening or fatal, cause congenital malformation and other events that occur during the clinical trial. we define treatment success as a patient whose throatswab sars-cov-2 real-time fluorescent reverse transcription polymerase chain reaction (rt-pcr) nucleic acid is positive at the beginning of the treatment but is negative at least twice consecutively after the treatment and remains negative. nasal stuffiness, nasal discharge, etc. (b) normal or decreased white-blood-cell counts in the early stages of disease; normal or decreased lymphocyte counts (c) multiple, small, patchy shadows and interstitial changes in the early stages of chest imaging, which are evident in the extrapulmonary zones, and which develop multiple "ground-glass" infiltrations and infiltrates throughout both lungs. in severe cases, pulmonary consolidation may occur, but the formation of pleural effusion is rare ③ confirmed conditions: fulfillment of any one of the epidemiological history items and any two of the clinical manifestation items or three clinical manifestation items if no epidemiological history is available, in addition to meeting one of the following etiological or serological criteria: any of the following factors will lead to exclusion: grouping is carried out using a centrally stratified, randomized block method. before the trial, a statistical expert will use sas software to set the number of centers at four, the block size will be four, the number of blocks will be 28, using a 1: 1 ratio between the experimental group and the control group, will generate 112 random numbers and corresponding grouping information. according to the haphazard allocation table used in advance, the statistical expert gives random numbers in ascending order. each random number and grouping information correspond to an envelope. the envelope is sealed and given to the researchers responsible for screening. qualified subjects are selected, and the envelopes are received in the order of enrollment. after the envelopes are opened, the random-number and grouping information is removed, so that the subjects will be randomly assigned to the experimental group or the control group, and the corresponding treatment and observations performed. each subject's random number is unique and remains the same throughout the trial. the hypothesis of this study is that the use of chloroquine phosphate instead of lopinavir/ritonavir will increase the rate of throat-swab sars-cov-2 nucleic-acid negative conversion. the main therapeutic index of this study is the clinical recovery time (after no more than 28 days), which is from the beginning of the study drug intervention treatment to the normalization of body temperature, respiratory symptoms, respiratory rate, and blood-oxygen saturation. in the later analysis, the log-rank method is used to compare the differences in clinical recovery time between the two groups of patients. the sample size of this study is calculated based on the log-rank method by using the log-rank test (lakatos) (median survival time) module in the pass 11.0 statistical software (see additional file: sample size report" for details). based on clinical experience [4, 18] , the median clinical recovery time of the patients in the control group is expected to be 8 days, and the median clinical recovery time of patients in the experimental group can be shortened to 4 days (corresponding hazard ratio (hr) = 2.0) 112 patients (56 in each group) will be required to detect this difference with a significant level of α = 0.05 (both sides) with 85% confidence interval. the trial is planned to be enrolled for 90 days, followed up for 28 days, and a final analysis is performed after 78 clinical recovery events occur. it is estimated that the drop-out rate of the experimental group and the control group is 5%. the results of this study for efficacy outcomes will be analyzed based on both intention-to-treat (itt) and per-protocol (pp) approaches with a primary consideration for itt results. a pp analysis will be performed secondarily. a safety analysis will be performed based on the safety group. the itt group will include participants who are randomized after satisfying the eligibility criteria and receive one study drug at least once and have post-dose evaluation data. the pp group will include participants who satisfy the following conditions among the itt group: (1) those who completed all planned visits and (2) those who did not receive and use drugs or treatments that may affect the evaluation of efficacy during the study. the safety analysis group will include participants who received study drugs at least once and have post-dose safety evaluation data. comparisons will be performed using two-sided tests with a statistical significance level of 5% unless stated otherwise. for the primary outcome of this trial, the clinical recovery time of no more than 28 days after the completion of therapy and follow-up will be estimated as the proportion with a 95% confidence interval (ci) for each treatment group. the difference between the control arm and the experimental arm will subsequently be determined using the log-rank test. in order to control the influence of possible confounding factors such as gender and age on the clinical recovery time, the cox proportional hazard model will be used to compare whether the clinical recovery time of the two groups is different, provide hrs and 95% cis. the analysis of secondary outcomes will be described as explorative outcomes. the rate of treatment success after the completion of therapy and follow-up among the two groups will be compared using the chi-square test or fisher's exact test. the time of treatment success after no more than 28 days, the time to normal temperature (calculated from the onset of illness) during the completion of therapy and follow-up will be calculated in each group and compared using the log-rank test. the rate of saes during the completion of therapy and follow-up will be compared among the two groups using the chi-square test or fisher's exact test. all aes according to the common terminology criteria for adverse events (ctcae) will be collected and documented, regardless of severity, seriousness, or relationship to the study drug. we will summarize all aes, include ae frequency and percentage, and 95% cis and compare the occurrence rate of aes in relationship to the study drug and the severity of the two arms using the chi-square test or fisher's exact test. primary and secondary outcomes will be analyzed separately in participants with throat-swab sars-cov-2 rt-pcr-positive and throat-swab sars-cov-2 rt-pcrpositive covid-19 infection. our study will use a paper version of the case report form (crf) and establish a clinical research database to record all the information in the crf. we will use the software epidata 3.1 for double data entry and proofreading of data, as well as manual verification and system verification. during the study, medical personnel not participating in this study will monitor this trial. monitors will visit the database to monitor all aspects of the study including adherence to the protocol and good clinical practice, protection of participants, and data accuracy of the study. the office of the clinical research center and the medical ethics committee of sun yat-sen university form the data and safety monitoring board. based on data review during the trial conduct, the board may provide recommendations such as protocol amendment, continuation, or stopping of the trial. the datasets analyzed during the current study are available from the corresponding author on reasonable request. we will collect the participants' personal information only when necessary to evaluate efficacy, safety, and tolerability of the study drugs. such information will be collected and processed, taking precautions for compliance with laws on privacy protection and the guarantee of confidentiality. paper files containing participants' data (including personally identifiable information and copies of signed consent forms) will be securely stored in a locked office on sites in locked filing cabinets. digital files containing participants' data will be stored in password-protected files on university-maintained servers. access to study files will be restricted to authorized personnel only. the items in the present study protocol comply with the standard protocol items: recommendations for interventional trials (spirit) checklist (see the spirit checklist and figure in additional file). the trial was registered under the registration number chictr2000029741 (http://www.chictr.org.cn/showproj. aspx?proj=49263) on 11 february 2020. on 10 february, 2020, this research was approved by the medical ethics committee of the fifth affiliated hospital of sun yatsen university, zdwy[2020] lunzi no. (k15-1). as of 10 april 2020, the total number of covid-19 infection diagnoses in the world was more than 1.3 million, with more than 80,000 deaths (https://www.who. int/dg/speeches/detail/the-cooperation-council-of-theturkic-speaking-states%2d%2d-10-april-2020). there is no known curative treatment for covid-19, neither novel treatments nor vaccines. cao' study observed no benefit with lopinavir/ritonavir treatment in severe covid-19 patients [19] . lim's study observed that the beta-coronavirus viral load significantly decreased with no or little coronavirus titers after administering lopinavir/ritonavir [2] . gautret's study [20] concluded that chloroquine is significantly associated with viral-load reduction/disappearance in covid-19 patients. in the seventh edition of the chinese version of the covid-19 diagnosis and treatment plan (http://www.nhc.gov.cn/ yzygj/s7653p/202003/46c9294a7dfe4cef80dc7f5912eb1 989/files/ce3e6945832a438eaae415350a8ce964.pdf), the recommended antiviral drugs are lopinavir/ritonavir, chloroquine phosphate and other drugs. the chinese have decreased the current epidemic situation in china by using the recommended drugs. the relief of the epidemic in most provinces of china has at least confirmed the effectiveness of the treatment to a certain extent, but further strong and effective, evidencebased data is needed. the trial will be conducted in a clinical outpatient and inpatient setting by experienced clinicians, and participants will be recruited from the patient base of the other three hospitals participating in the trial. the purpose of this prospective, open-label, multicenter randomized controlled, comprehensive clinical study is to evaluate the efficacy and safety of chloroquine phosphate and lopinavir/ritonavir in patients with mild/general covid-19 infection. the results of this study should provide meaningful information and evidence for clinical practice and should help to design a proven and reasonable rct soon. randomized controlled studies still have some design limitations. first, the sample size we use is relatively small and the 28-day treatment period is short. therefore, we will not be able to estimate possible relapses of pneumonia after long-term treatment. second, the pathophysiology of novel coronavirus pneumonia has not been elucidated. as only clinician assessment is used (including lung computed tomography (ct) results and count of viral load), there is no objective indicator to judge the effect of treatment on covid-19 infection. finally, the follow-up period in this study was relatively short. in light of these limitations, we will develop a more reasonable treatment cycle and follow-up period to explore the efficacy of chloroquine in patients with covid-19. we also know that there will be many biases in the open trial, and we have taken a number of measures to control the possible bias in the trial, as follows: (1) strict exclusion criteria are formulated to effectively control other confounding factors that may affect the efficacy; (2) the trial uses random grouping to ensure that the two groups of patients are comparable; (3) before the patient signs the informed consent form, the researchers and the patients make full communication to ensure that the patients understand the entire trial content, and try to eliminate the impact of the patient's psychological state on the trial effect; (4) the main and secondary indicators for evaluating the efficacy are objective indicators to avoid the influence of subjective factors; (5) before the start of the trial, the researchers will conduct unified system training to ensure the uniformity and correctness of data collection and index evaluation. the trial was registered under the registration number chictr2000029741(http://www.chictr.org.cn/showproj. aspx?proj=49263) on 11 february 2020. on 10 february 2020, this study was approved by the medical ethics committee of the fifth affiliated hospital of sun yatsen university in zhuhai, zdwy[2020] lunzi no. (k15-1). unique protocol id: zdwy.grbk.011. protocol version date: 7 february 2020. the first participant was randomized in february 2020, and recruitment is ongoing. it is estimated that the recruitment will be completed on 31 may 2020. the final results will be reported next year. supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04478-w. human coronavirus: host-pathogen interaction case of the index patient who caused tertiary transmission of covid-19 infection in korea: the application of lopinavir/ ritonavir for the treatment of covid-19 infected pneumonia monitored by quantitative rt-pcr clinical efficacy of lopinavir/ritonavir in the treatment of coronavirus disease 2019 arbidol combined with lpv/r versus lpv/r alone against corona virus disease 2019: a retrospective cohort study effects of chloroquine on viral infections: an old drug against today's diseases? changes in function of iron-loaded alveolar macrophages after in vivo administration of desferrioxamine and/or chloroquine mechanism of borna disease virus entry into cells endocytosis is a critical step in entry of subgroup b avian leukosis viruses chloroquine, an endocytosis blocking agent, inhibits zika virus infection in different cell models effect of chloroquine on reducing hiv-1 replication in vitro and the dc-sign mediated transfer of virus to cd4+ t-lymphocytes anti-malaria drug chloroquine is highly effective in treating avian influenza a h5n1 virus infection in an animal model chloroquine inhibits endosomal viral rna release and autophagy-dependent viral replication and effectively prevents maternal to fetal transmission of zika virus in vitro inhibition of severe acute respiratory syndrome coronavirus by chloroquine chloroquine is a potent inhibitor of sars coronavirus infection and spread inhibition of human coronavirus 229e infection in human epithelial lung cells (l132) by chloroquine: involvement of p38 mapk and erk evolution of the novel coronavirus from the ongoing wuhan outbreak and modeling of its spike protein for risk of human transmission remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-ncov) in vitro treating covid-19 with chloroquine a trial of lopinavir-ritonavir in adults hospitalized with severe covid-19 hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations professor jx carried out the design of the study. mh and zh, carried out the design of the study. xl, participated in the study design and drafted the manuscript. hc and ys, participated in the study design and drafted the manuscript. hz and gc helped to draft the manuscript. yc, sl and yz will follow the research and help to collect data. all authors read and approved the final manuscript. the datasets used or analyzed in the current study are available from the corresponding author on reasonable request. this study was reviewed and approved by the medical ethics committee of the fifth affiliated hospital of sun yat-sen university in zhuhai on 10 february 2020, with file number zdwy[2020] lunzi no. (k15-1). this study is designed in accordance with the principles of the declaration of helsinki. all participants will provide written informed consent before enrollment. the authors declare that they have no competing interests.author details key: cord-315149-71bmj5il authors: caballero bermejo, antonio f.; ruiz-antorán, belén; fernández cruz, ana; diago sempere, elena; callejas díaz, alejandro; múñez rubio, elena; avendaño-solá, cristina; ramos martínez, antonio; sancho lópez, aránzazu title: sarilumab versus standard of care for the early treatment of covid-19 pneumonia in hospitalized patients: sartre: a structured summary of a study protocol for a randomised controlled trial date: 2020-09-16 journal: trials doi: 10.1186/s13063-020-04633-3 sha: doc_id: 315149 cord_uid: 71bmj5il objectives: in some patients, acute, life-threatening respiratory injury produced by viruses such as sars-cov and other viral pneumonia are associated with an over-exuberant cytokine release. elevated levels of blood il-6 had been identified as a one of the risk factors associated with severe covid-19 disease. anti-il6 inhibitors are among the therapeutic armamentarium for preventing the fatal consequences of acute respiratory and multi organ failure in around 20% of the covid-19 infected patients. at present, their use is prioritized to patients with severe interstitial pneumonia (brescia-covid scale-covid 2-3) with hyperinflammation as determined by the presence of elevated il6 and/or d-dimer, or progressive d-dimer increase, in patients who otherwise are subsidiary to icu admission. however, many uncertainties remain on the actual role of anti-il6 inhibitors in this setting, and whether current use and timing is the right one. there is the hypothesis that the use of anti-il6 inhibitors at an earlier state during the hyperinflammatory syndrome would be beneficial and may avoid progressing to ards. on the other hand, the standard of care has changed and nowadays the use of corticosteroids has become part of the soc in the treatment of covid-19 pneumonia. our limited experience suggests that better treatment outcomes can be achieved when combining il6-inhibitors (e.g. sarilumab) with corticosteroids. the aim of the present study is to evaluate if an earlier therapeutic intervention with sarilumab plus soc (including corticosteroids) may be more effective than current standard of care alone, in preventing progression to respiratory failure in covid-19 infected patients with interstitial pneumonia. this study will also provide supportive evidence to that provided by currently ongoing studies on the efficacy and safety of sarilumab in this clinical context. trial design: a phase two multi-center randomised controlled trial (rct) with two parallel arms (1:1 ratio). participants: they will be hospitalized patients, of at least 18 years of age, with severe covid-19 who have positive rt-pcr test and have radiographic evidence of pulmonary infiltrates by imaging or rales/crackles on exam and spo2 ≤ 94% on room air that requires supplemental oxygen. patients must present elevation of inflammatory parameters (il-6 > 40 pg/ml or d-dimer >1.0 mcg/ml) or, alternatively, progressive worsening in at least two of these inflammatory parameters in the prior 24-48h: crp, ldh, serum ferritin, lymphopenia, or d-dimer. exclusion criteria: high oxygen requirements (including face mask with reservoir, non-invasive mechanical ventilation or high flow nasal cannula, or mechanical ventilation), admission to icu, pregnancy or lactation, allergy or hypersensitivity to sarilumab or corticoesteroids, immunosuppressive antibody therapy within the past 5 months, ast/alt values > 10 x uln, neutropenia (< 0.5 x 109/l), severe thrombocytopenia (< 50 x 109/l), sepsis caused by an alternative pathogen, diverticulitis with risk of perforation or ongoing infectious dermatitis. the study will be conducted in several hospitals in spain. intervention and comparator: patients randomised to the experimental arm will receive sarilumab + methylprednisolone plus soc for covid-19. patients included in the control arm will receive methylprednisolone plus soc for covid-19. corticosteroids will be given to all patients at a 1mg/kg/d of methylprednisolone for at least 3 days. clinical follow-up visits will be performed at 3, 5, and 15 days after treatment randomization. patients in the control group (soc group without sarilumab) progressing to bresciacovid 2-3 plus inflammatory markers, will be given the option to be rescued with sarilumab at the same doses and, in that case, be included in an open-label phase and be followed up for additional weeks (with visits at 3, 7 and 15 days after sarilumab rescue administration). patients randomly assigned to sarilumab therapy at baseline progressing to brescia-covid 2-3 will be rescued according to local clinical practice protocols. a final follow-up visit will be conducted for all patients at day 29 from randomization, regardless of initial treatment assignment. main outcomes: primary end point is the proportion of patients progressing to either severe respiratory failure (brescia-covid ≥2), icu admission, or death. randomization: randomization codes were produced by means of the proc plan of the sas system, with a 1:1 assignment ratio, stratifying by centre and using blocks multiple of 2 elements. the randomization schedule will be managed through the ecrf in a concealed manner. blinding (masking): all study drugs will be administered as open label. no blinding methods will be used in this trial. numbers to be randomised (simple size): the target sample size will be 200 covid-19 patients, who will be allocated randomly to control arm (100) and treatment arm (100). trial status: protocol code: sartre protocol date: may 05th 2020. version: 2.0 the study has been approved by the spanish competent authority (aemps) as a low intervention clinical trial. start of recruitment: august, 2020 end of recruitment: may, 2021 trial registration: identifier: eudract number: 2020-002037-15; registration date: 26 may 2020. full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. the study protocol has been reported in accordance with the standard protocol items: recommendations for clinical interventional trials (spirit) guidelines (additional file 2). investigational product srlmb is a recombinant human immunoglobulin (igg) 1 monoclonal antibody that binds specifically to both soluble and membrane-bound interleukin-6 (il-6) receptors (sil-6rα and mil-6rα) and inhibits il-6-mediated signaling. it is approved for the treatment of moderate to severe rheumatoid arthritis. the recommended dose of sarilumab is 200 mg once every 2 weeks administered as a subcutaneous injection. a multicenter, randomized, open-label study to evaluate the efficacy and safety of sarilumab + standard of care versus standard of care for the early treatment of covid-19pneumonia in hospitalized patients. rationale for the study in some patients, acute, life-threatening respiratory injury produced by viruses such as sars-cov and other viral pneumonia are associated with an over-exuberant cytokine release. elevated levels of blood il-6 had been identified as a one of the risk factors associated with severe covid-19 disease. preliminary experiences with tocilizumab, an anti-il6 inhibitor, show promising results with improvements seen in clinical symptoms, respiratory function, and inflammatory laboratory parameters. based on this and on current knowledge on the role of the anti-il6 inhibitor tocilizumab in the treatment of cytokine release syndrome associated to cart therapies, tocilizumab is being extensively used nowadays in clinical practice, and many clinical trials are being conducted around the world, for preventing the fatal consequences of acute respiratory and multi organ failure associated with acute respiratory syndrome due to severe covid-19 infection. in spain, anti-il6 inhibitors are among the therapeutic armamentarium for preventing the fatal consequences of acute sartre study eudract number: 2020-002037-15 version 2.0 (may 05th 2020) respiratory and multi organ failure in around 20% of the covid-19 infected patients. at present, their use is prioritized to patients with severe interstitial pneumonia (brescia-covid scale-covid 2-3) with hyperinflammation as determined by the presence of elevated il6 and/or d-dimer, or progressive d-dimer increase, in patients who otherwise are subsidiary to icu admission. preliminary results of an unpublished ongoing multicenter, national, observational cohorts study conducted in patients treated with tocilizumab vs matched controls led by our group suggest that il-6 inhibitors may prevent progression to icu admission or death in patients with severe covid-19 interstitial pneumonia. however, many uncertainties remain on the actual role of anti-il6 inhibitors in this setting, and whether current use and timing is the right one. among clinicians there is the hypothesis that the use of anti-il6 inhibitors at an earlier state during the hyperinflammatory syndrome would be beneficial and may avoid progressing to ards. on the other hand, the standard of care has changed in the prior weeks and nowadays the use of corticosteroids has become part of the soc in the treatment of covid-19 pneumonia, and our limited experience suggests that better treatment outcomes can be achieved when combining il6-inhibitors with corticosteroids. thus, the question still remains on whether anti-il6 inhibitors concomitantly with corticosteroids may potentiate the antiinflammatory response and lead to better disease outcomes. the aim of the present study is to evaluate if an earlier therapeutic intervention with sarilumab plus soc may be more effective than current standard of care alone, which according to our local protocol includes weight adjusted corticosteroids doses, in preventing progression to respiratory failure in covid-19 infected patients with interstitial pneumonia. this study will also provide supportive evidence to that provided by currently ongoing studies on the efficacy and safety of sarilumab in this clinical context. 4. to evaluate differences in the effect of sarilumab on the serum levels of inflammatory cytokines. 5 . to evaluate differences in the proportion of patients showing more than >1 organ failure, e.g. cardiovascular, liver and kidney failure 6. to identify prognosis factors of sarilumab efficacy related to laboratory parameters or disease features. to obtain a power of 80.00% to detect differences in the contrast of the null hypothesis h₀: p1 = p2 by means of a bilateral chi square test for two independent samples, taking into account that the level of significance is 5.00%, and assuming that the sartre study eudract number: 2020-002037-15 version 2.0 (may 05th 2020) proportion in the reference group is 25.00%, the proportion in the experimental group is 10.00%, and a randomization ratio 1.1, it will be necessary to include 100 patients in the reference group and 100 patients in the experimental group, with a total of 200 patients in the study. 1. patients willing to provide informed consent to participate in this study. witnessed oral consent will be accepted in order to avoid paper handling. written consent by patient or representatives will be obtained whenever possible. 2. the patient is at least 18 years of age. 3. the patient is positive for novel coronavirus by real-time rt-pcr 4. the patient is hospitalized for covid-19 without either mechanical ventilation (invasive or non-invasive) or oxygen mask with reservoir bag and at least one of the following: -radiographic evidence of pulmonary infiltrates by imaging (chest x-ray, ct scan, etc.), -clinical assessment (evidence of rales/crackles on exam) and spo2 ≤ 94% on room air that requires supplemental oxygen. 5. more than 7 days between the onset of symptoms (fever, dysnea, and/or cough) and treatment administration day. in the absence of fever, cough, or dyspnea, other symptoms like asthenia, headache, or gastrointestinal symptoms may be considered 6. the patients presents progressive elevation of inflammatory parameters suggestive of a hyperinflammatory syndrome: presence of elevated il-6 (>40pg/ml) or elevated d-dimer (>1.0 mcg/ml), or alternatively, progressive worsening in at least two of these inflammatory parameters in the prior 48h: crp, ldh, serum ferritin, lymphopenia, or ddimer. 1. requiring mechanical ventilation (invasive or non-invasive) or oxygen mask with reservoir bag at screening. 2. participation in any other clinical trial of an experimental treatment for covid-19. 3. in the opinion of the clinical team, progression to death is imminent and inevitable within the next 24 hours, irrespective of the provision of treatments. 4 . any incompatibility or allergy to the administration of sarilumab or corticosteroids. sarilumab will be administered intravenously following this posology: -patients <75kg body weight: single 200mg sarilumab dose (1 single-dose pre-filled syringe containing 200 mg sarilumab in 1.14 ml solution (175 mg/ml) added to 100 ml 0.9% sodium chloride for a 1-hour intravenous infusion). -patients ≥75kg body weight: single 400mg sarilumab dose (2 single-dose pre-filled syringes, each containing 200 mg sarilumab in 1.14 ml solution (175 mg/ml) added to 100 ml 0.9% sodium chloride for a 1-hour intravenous infusion). in addition, all study participants will receive treatment with corticosteroids intravenously following this posology: methylprednisolone 1mg/kg/day (or corticosteroid dose equivalents) for at least 3 days sarilumab plus corticosteroids or corticosteroids alone will be given in add-on to soc medication. soc medication will be based on local clinical practice recommendations. the observation period will be from randomization until 28 days after randomisation, hospital discharge, icu admission or death, whichever occurs first. a multi-center, randomized, clinical trial with two arms to study the efficacy and safety of early treatment with sarilumab plus soc compared to standard of care (soc) in patients with covid-19 pneumonia (bcrss score 1). experimental arm: sarilumab + methylprednisolone (or equivalent doses) plus soc for covid-19 control arm: methylprednisolone (or equivalent doses) plus soc for covid-19. randomization will be 1:1 to any of the treatment groups and will be stratified per center. methylprednisolone 1mg/kg/day (or corticosteroid dose equivalents) for at least 3 days. soc includes any drugs that are being used in clinical practice (e.g. lopinavir/ritonavir; hydroxy/chloroquine, and other than those used as part of another clinical trial) according to each site local protocol. patients will be followed up to four weeks after randomization. patients randomized to the control arm (cs + soc group without sarilumab) progressing to severe respiratory failure fulfilling criteria for treatment with anti-il6 inhibitors according to clinical practice guidelines, as defined by the presence of brescia-covid sartre study eudract number: 2020-002037-15 version 2.0 (may 05th 2020) scale 2-3 plus inflammatory markers, will be offered the option to be rescued with sarilumab at the same doses and be included in an open-label follow-up phase. this group of patients will be followed up for two additional weeks following sarilumab administration. the results of the study will also be compared with an external cohort of matched patients that did not receive il-6 inhibitors. this cohort of patients is already being collected as part of an academic multicenter, national, prospective observational cohorts study being conducted by the same investigation team. this will provide further contextualization to our results and facilitate interpretation. primary measure and endpoint: the primary endpoint is the proportion of patients progressing to severe respiratory failure (brescia-covid scale ≥2), icu admission, or death. time to progression to severe respiratory failure (brescia-covid ≥2) time to non-invasive or invasive mechanical ventilation. this will be a multicenter national study, with hospital universitario puerta de hierro majadahonda acting as study site coordinator. the list of participating centers can be found attached as appendix 7. expected recruitment will take 2 months since first site initial visit, which will follow the approval of the aemps. each patient will participate in the trial for a maximum of 29 days, including a screening phase of 1 day, treatment duration of 1-2 day, initial follow-up and a follow-up visit at 28 days from randomisation. two hundred patients kevzara® (sarilumab) is a fully human igg1 monoclonal antibody that binds specifically to both soluble and membrane-bound il-6 receptors (sil-6rα and mil-6rα) and has been shown to inhibit il-6-sartre study eudract number: 2020-002037-15 version 2.0 (may 05th 2020) mediated signaling through these receptors. il-6 is a pleiotropic pro-inflammatory cytokine produced by a variety of cell types including t-and b-cells, lymphocytes, monocytes and fibroblasts. il-6 has been shown to be involved in diverse physiological processes such as migration and activation of tcells, induction of immunoglobulin secretion, initiation of hepatic acute phase protein synthesis, and stimulation of hematopoietic precursor cell proliferation and differentiation. kevzara® (sarilumab) is authorized in the european union for the treatment of adult patients with moderately to severely active rheumatoid arthritis (ra) who have had an inadequate response or intolerance to one or more biologic or non-biologic disease-modifying anti-rheumatic drugs (dmards). the recommended dose is 200 mg once every 2 weeks given as a subcutaneous injection. in some patients, acute, life-threatening respiratory injury produced by viruses such as sars-cov and other viral pneumonia are associated with an over-exuberant cytokine release. elevated levels of blood il-6 had been identified as a one of the risk factors associated with severe covid-19 disease. preliminary experiences with tocilizumab, an anti-il6 inhibitor, show promising results with improvements seen in clinical symptoms, respiratory function, and inflammatory laboratory parameters. based on this and on current knowledge on the role of the anti-il6 inhibitor tocilizumab in the treatment of cytokine release syndrome associated to cart therapies, tocilizumab is being extensively used nowadays in clinical practice, and many clinical trials are being conducted around the word, for preventing the fatal consequences of acute respiratory and multi organ failure associated with acute respiratory syndrome due to severe covid-19 infection. in spain, anti-il6 inhibitors are among the therapeutic armamentarium for preventing the fatal consequences of acute respiratory and multi organ failure in around 20% of the covid-19 infected patients. at present, their use is prioritized to patients with severe interstitial pneumonia (covid2-3) with hyperinflammation as determined by the presence of elevated il6 and/or d-dimer, or progressive d-dimer increase, in patients who otherwise are subsidiary to icu admission. preliminary results of an unpublished ongoing multicenter, national, observational cohorts study conducted in patients treated with tocilizumab vs matched controls led by the same local investigation team suggest that il-6 inhibitors may prevent progression to icu admission or death in patients with severe covid-19 interstitial pneumonia and that there is a window of opportunity for this drug, yet to be determined. however, many uncertainties remain on the actual role of anti-il6 inhibitors in this setting, and whether current use and timing is the right one. among clinicians there is the hypothesis that the use of anti-il6 inhibitors at an earlier state during the hyperinflammatory syndrome than the current one would be beneficial and may avoid progressing to ards. on the other hand, the standard of care has changed in the prior weeks and nowadays the use of corticosteroids has become part of the soc in the treatment of covid-19 pneumonia, and our limited experience suggests that better treatment outcomes can be achieved when combining il6-inhibitors with corticosteroids. thus, the question still remains on whether anti-il6 inhibitors concomitantly with corticosteroids may potentiate the anti-inflammatory response and lead to better treatment outcomes. eudract number: 2020-002037-15 version 2.0 (may 05th 2020) the hypothesis of this trial is that in patients with pneumonia and respiratory failure caused in the setting of covid-19, an early blockade of il-6 with sarilumab plus weight adjusted corticosteroid doses plus soc, will attenuate the cytokine storm and halt the progression to acute respiratory distress syndrome (ards) and the need for mechanical ventilation, icu admission, or death. the overall objective of the study is to evaluate the efficacy of an early intervention with sarilumab in the prevention of progression to severe respiratory failure/icu admission or death in covid-19 infected patients with pneumonia and regular oxygen supplement requirements (brescia-covid-1). 1. to assess differences between both strategies in the following: 2. to evaluate safety of sarilumab treatment in treating patients with covid-19 pneumonia. 3. to evaluate differences in the effect of sarilumab on the serum levels of inflammatory cytokines in patients with covid-19. 4 . to evaluate differences in the proportion of patients showing more than >1 organ failure, e.g. cardiovascular, liver and kidney failure 5. to identify prognosis factors of sarilumab efficacy related to laboratory parameters or disease features the primary endpoint is the proportion of patients progressing to severe respiratory failure (brescia-covid >2), icu admission or death from randomization up to day 15th of follow-up. secondary to evaluate safety of sarilumab as compared to soc safety through day 29 · cumulative incidence of serious adverse events (saes) · cumulative incidence of grade 3 and 4 adverse events (aes). sartre study eudract number: 2020-002037-15 version 2.0 (may 05th 2020) changes in serum level of crp, il-6, lymphocyte count, neutrophils count, d-dimer, ldh, ferritin, coagulation tests to evaluate differences in the proportion of patients showing more than >1 organ failure, e.g. cardiovascular, liver and kidney failure patients showing more than >1 organ failure through day 15 to identify prognosis factors of sarilumab efficacy related to laboratory parameters or disease features focused medical history, demographic characteristics, covid-19 history, concomitant medication, and laboratory disease parameters. this is an exploratory phase ii, multicenter, open-label, randomized clinical trial to evaluate the efficacy and safety of an early intervention with sarilumab + methylprednisolone (or equivalent cs dose) plus soc vs methylprednisolone (or equivalent cs dose) plus soc alone in patients with covid-19 pneumonia aimed to prevent progression to severe respiratory failure, icu admission, or death. control arm: methylprednisolone plus soc for covid-19. sarilumab will be administered intravenously following this posology: -patients <75kg body weight: single 200mg sarilumab dose (1 single-dose pre-filled syringe containing 200 mg sarilumab in 1.14 ml solution (175 mg/ml) added to 100 ml 0.9% sodium chloride for a 1-hour intravenous infusion). -patients ≥75kg body weight: single 400mg sarilumab dose (2 single-dose pre-filled syringes, each containing 200 mg sarilumab in 1.14 ml solution (175 mg/ml) added to 100 ml 0.9% sodium chloride for a 1-hour intravenous infusion). corticosteroids will be given to all patients at a 1mg/kg/d of methylprednisolone (or equivalent cs dose) for at least 3 days. soc includesing weight adjusted corticosteroid doses plus any drugs that are being used in clinical practice (e.g. lopinavir/ritonavir; hydroxy/chloroquine, and other than those used as part of another clinical trial randomization will be 1:1 to any of the treatment groups and will be stratified per center. for patients on will be rescued with sarilumab at the same doses and be included in a 15-day openlabel follow up phase or until hospital discharge, icu admission or death. clinical follow-up visits will be performed at 3, 5, and 15 days after treatment randomization. patients in any treatment group progressing to severe respiratory failure fulfilling criteria for treatment with anti-il6 inhibitors according to clinical practice guidelines, as defined by the presence of brescia-covid 2-3 plus inflammatory markers, will be considered treatment failures for the sake sartre study eudract number: 2020-002037-15 version 2.0 (may 05th 2020) of the primary analysis and be rescued according to local treatment protocols, which may include tocilizumab. patients in the control group (soc group without sarilumab) progressing to brescia-covid 2-3 plus inflammatory markers, will be given the option to be rescued with sarilumab at the same doses and, in that case, be included in an open-label phase and be followed up for two additional weeks (with visits at 3, 7 and 15 days after sarilumab rescue administration). a final follow-up visit will be conducted for all patients at d29 from randomization, regardless of initial treatment assignment. 1. informed consent prior to performing any study procedure. witnessed oral consent will be accepted in order to avoid paper handling. written consent by patient or representatives will be obtained whenever possible. 2. male or female adult patients of at least 18 years of age. 3. the patient is positive for sars-cov-2 by real-time pcr or other validated tests 4. the patient is hospitalized for covid-19 without either mechanical ventilation (invasive or non-invasive) or oxygen mask with reservoir bag and at least one of the following: -radiographic evidence of pulmonary infiltrates by imaging (chest x-ray, ct scan, etc.), -clinical assessment (evidence of rales/crackles on exam) and spo2 ≤ 94% on room air that requires supplemental oxygen. 5. more than 7 days between the onset of symptoms (fever, cough, and/or dyspnea) and treatment administration day. in the absence of fever, cough, or dyspnea, other symptoms like astenia, headache, or gastrointestinal symptoms may be considered. 6. the patient present progressive elevation of inflammatory parameters suggestive of a hyperinflammatory syndrome : -presence of elevated il-6 (>40 pg/ml) or -elevated d-dimer (>1.0 mcg/ml), or alternatively, progressive worsening in at least two of these inflammatory parameters in the prior 24-48h: crp, ldh, serum ferritin, lymphopenia, or d-dimer. 7. patient must be, in the investigator opinion, able to comply with all the protocol procedures. 4. in the opinion of the clinical team, progression to death is imminent and inevitable within the next 24 hours, irrespective of the provision of treatments. 5 . any hypersensitivity or allergy to the administration of sarilumab or corticosteroids. 6. current treatment with immunosuppressive or any immunomodulatory medication within 8 weeks of baseline. 11. sepsis caused by an alternative pathogen. 12. diverticulitis with risk of perforation. 13. ongoing infectious dermatitis. 14. patients with another active infection, including localized infections. 15. pregnant or breast-feeding females will be excluded this is a multicenter, randomized, open label clinical trial evaluating the safety and efficacy of sarilumab (kevzara®) for the early treatment of the hyperinflammatory syndrome caused by the infection with sars cov 2. this open-label trial will use blind randomization of patients in a 1:1 ratio to sarilumab (plus corticosteroids) or soc (plus corticosteroids) through a centralized system embedded in the ecrf (oracle clinical). randomization will be stratified by site. experimental group: patients in the treatment arm will receive sarilumab plus corticosteroids on top of soc medication. sarilumab will be administered intravenously as a single dose following this posology: -patients ≥75kg body weight: single 400mg sarilumab dose (2 single-dose pre-filled syringes, each containing 200 mg sarilumab in 1.14 ml solution (175 mg/ml) added to 100 ml 0.9% sodium chloride for a 1-hour intravenous infusion). -corticosteroids will be administered intravenously following this posology: methylprednisolone 1mg/kg/day (or corticosteroid dose equivalents) for at least 3 days control group: patients in the control group will receive corticosteroids on top of soc medication. corticosteroid: will be administered intravenously following this posology: methylprednisolone 1mg/kg/day (or corticosteroid dose equivalents). soc: all patients will continue background soc according to local clinical practice protocols and be followed up until disease progression, patient withdrawal, icu admission, hospital discharge, loss of follow up, or death. storage, distribution, and usage of these materials in accordance with the protocol and any applicable laws and regulations. dose formulation: storage: each box will be stored at the site at a temperature of 2ºc to 8ºc packaging and labelling: study intervention will be provided in box by sanofi. each box will contain 2 prefilled syringes and will be labelled as required by local regulation. after removing the syringes from the refrigerator, they should be allowed to reach room temperature (<25°c). before starting the dilution procedure, the clinical center (pharmacist or nurse) will check that the syringes used for dilution do not contain any particles or discoloration. if any particulate matter, cloudiness or discoloration is detected, the syringe is to be quarantined, prohibited from use and reported to the sponsor. imp will not be removed. sarilumab prefilled syringe (1or 2 syringes for 200 mg or 400 mg dosage, respectively) will be diluted under aseptic conditions in 100 ml 0.9% sodium chloride solution bag.the infusion bag will be turned upside down at least three times to ensure a good mixing of the solutions. the infusion will be administered within 30 minutes from the end of preparation (as no mixture stability is known). the product will be infused using a volumetric pump at the protocol-specific use and reported to the sponsor. imp will not be removed from the box until just before dosing in order to protect from light. incompatibilities: this medicinal product must not be mixed with other medicinal products. the local hospital pharmacist or nurse will prepare the treatment dose required for each patient. individual treatment dose is prepared in the preparation area of the pharmacy, at a workstation free from any items not needed for this operation, and will be performed in aseptic conditions, as per local rules. safety measures for preparation and handling include protective clothing, gloves, and safety cabinets. serious infections: patients should be closely monitored for the development of signs and symptoms of infection during treatment with kevzara®. as there is a higher incidence of infections in the elderly population in general, caution should be used when treating the elderly. laboratory abnormalities: the activity of sarilumab in reducing inflammation is associated with laboratory changes such as decrease in anc and elevation in lipids. please refer to the smpc for additional precautionary measures during sarilumab treatment (appendix 5) premedication is not required prior to the administration of sarilumab unless deemed medically necessary by the investigator. any participant experiencing an infusion-related reaction (irr) must receive appropriate medical treatment. when the participant's condition is stable, the infusion may be restarted at a slower rate. in general, upon restarting, the infusion rate must be decreased by half at the time the infusion was interrupted. all study drugs will be administered as open label. no blinding methods will be used in this trial. experimental drugs will be supplied to pharmacies packaged and labeled according to the standard requirements for clinical trials. sarilumab will be labelled with the study protocol code, batch number, content, expiry date, storage conditions, investigator and sponsor name. the study medication will be labelled in accordance with annex 13 of the european good manufacturing practices. each infusion bag will be clearly marked with the following information: all study treatment supplies must be stored in accordance with the manufacturer's instructions and package labeling. until dispensed to the participants, the study treatment will be stored in a securely locked area, accessible to authorized personnel only. all study interventions must be stored in a secure, environmentally controlled, and monitored (manual or automated) area in accordance with the labeled storage conditions with access limited to the investigator and authorized site staff. upon receipt, sarilumab will be placed into a refrigerator and stored between +2°c and +8°c. the investigator or designee must confirm appropriate temperature conditions have been maintained during transit for all study intervention received and any discrepancies are reported and resolved before use of the study intervention. if a temperature excursion occurs: -the affected products will be placed in quarantine immediately with a clear sign of "quarantined" and clearly separated from the rest of the supplies. in addition, the affected products will be stored under proper conditions as per storage requirements. -the site monitor will be informed about the temperature excursion within the same business day. only participants enrolled in the study may receive study intervention and only authorized site staff may supply or administer study intervention. the investigator agrees that study drug will be dispensed by the investigator or sub-investigator(s) named on the investigator agreement or their qualified designees. the investigator, sub-investigators, or qualified designees also agree that the study drug(s) will be dispensed only to study subjects who have provided written informed consent (or oral consent where appropriate) and have met all entry. the investigator or the institution, is responsible for study intervention accountability, reconciliation, and record maintenance (i.e., receipt, reconciliation, and final disposition records). an accurate accountability record of products received, dispensed, discarded and returned or sartre study eudract number: 2020-002037-15 version 2.0 (may 05th 2020) destroyed by the pharmacy at the investigator site will be maintained on pharmacy file. participants will receive study intervention directly from the investigator or designee, under medical supervision. the date and time of each dose administered in the clinic will be recorded in the source documents and reported in the case report form (crf). the dose of study intervention and study participant identification will be confirmed at the time of dosing by a member of the study site staff other than the person administering the study intervention. sarilumab will be intravenously administered to participants at the site. precaution will be taken to avoid direct contact with the study interventions. in the case of unintentional occupational exposure notify the medical monitor. sarilumab is for single use only. any waste material should be disposed of in accordance with local requirements. unused medicinal product can be used as rescue medication of the study participants. non-used medication will be returned to sanofi or kept at local pharmacy for regular use upon sponsor agreement. medication will not be destroyed. participants should receive full supportive care during the study, as well as treatment with antibiotics and analgesics, as appropriate. all concomitant therapies will be permitted. no restriction is established regarding concomitant treatment. only clinical relevant concomitant treatment related to covid-19 will be recorded for the purposes of the trial. the list of concomitant medications will be assessed from 8 weeks prior to enrolment to end of study. the following medications are prohibited while receiving protocol therapy: · concomitant administration of tocilizumab. · any investigational agents other than sarilumab. · concurrent use of live vaccines. · other immunomodulators or immunosuppressant medications. patients are free to withdraw from participation in the study at any time. patients are listed as having withdrawn consent only when they no longer wish to participate in the study and no longer authorize the investigators to make efforts to continue to obtain their outcome data. every effort should be made to encourage patients to remain in the study for the duration of their planned outcome assessments. in the case of a patients becoming lost to follow-up, attempts to contact the patient be made and documented in the patient's medical records. treatment discontinuation is not foreseen given that sarilumab therapy will be given as a single dose administration during the initial randomized phase. for patients progressing to severe sartre study eudract number: 2020-002037-15 version 2.0 (may 05th 2020) respiratory failure, the study foresees the possibility to administer sarilumab as rescue therapy under certain conditions. patients may decide not to receive sarilumab in this second phase of the study without any justification, but efforts should be made by investigators to collect reasons behind and to continue to obtain their outcome data. investigators may choose to discontinue treatment in this second phase due to severe toxicity to sarilumab during prior administration or due to any other medical reason for which treatment with sarilumab is not considered a suitable choice for the patient. a patient may be removed from the study treatment for the following reasons; however, whenever possible the patient should be followed regardless of their protocol adherence as per the efficacy and safety evaluations: • patient withdraws consent or requests discontinuation from the study for any reason • termination of the study • lost to follow-up. • due to toxicity, depending on the severity and the relationship of the adverse event to the experimental therapy. patients who withdraw from this study or are lost to follow-up after signing the informed consent form (icf) (or giving oral consent) and administration of the study product, will not be replaced. the reason for patient discontinuation from the study will be recorded on the appropriate case report form. patients with suspicion of covid-19 pneumonia will be evaluated by the investigators at the participating sites. oral consent will be accepted in order to avoid paper handling. investigator must reflect the process of obtaining consent in the patient's clinical documentation. written consent by patient or representatives will be obtained whenever possible. patients will be screened in the hospitalization ward by the investigators of the trial. screening will take place within 1 day of selection, and administration of the first dose of sarilumab will be done within the following 24 hours. screening will be preceded by a presentation of the complete information about the clinical study to the subject or family member by the investigator followed by signature of the informed consent form or by obtaining oral consent. after the informed consent, all the following assessments are performed to determine eligibility requirements as specified in the inclusion and exclusion criteria and before the patient receives any study medication: -positive sars-cov-2 test result. laboratory-confirmed sars-cov-2 infection as determined by pcr in naso/oropharyngeal swabs or any other relevant. -focused physical examination: including vital signs, weight, auscultation, signs of respiratory distress, and any other as clinically indicated -oxygen supplement requirements: type and fio2 -oxygen parameters: sao2, pao2 (if available), sao2 or pao2/fio2 indexes -review recent radiographic imaging (x-ray or ct scan), valid up to 96h prior to randomisation. -laboratory disease parameters (il-6, ldh, d-dimer, crp, bun, ferritin, total white blood cell and total lymphocytes count, platelets count, and liver enzyme studies), valid within 24h prior to randomization -optional blood samples will be collected at baseline for future pharmacogenomic exploratory research* -pregnancy test (pregnancy test in women of childbearing potential) -brescia-covid scale, curb-65 -adverse events the overall eligibility of the subject to participate in the study will be assessed once all screening values are available. the screening process can be suspended prior to complete assessment at any time if exclusions are identified by the study team. study subjects who qualify will be immediately randomized and treatment should be administered within 24 hours after randomization. *optional blood samples for exploratory research. for patients agreeing to participate and signing the specific biobank informed consent, two additional blood samples will be collected at baseline: · one yellow tube with gel (5 ml), to collect serum after centrifugation. · one violet edta tube (5 ml) to collect plasma and buffy coat after centrifugation. specific details to collect and store these samples will be provided to all participating centers. note: the data of all the procedures carried out as part of the customary healthcare before the informed consent shall be recorded in the study and do not have to be repeated after the consent is given, if they are obtained in a time period of 48h. sartre study eudract number: 2020-002037-15 version 2.0 (may 05th 2020) participants will be randomly assigned to: -treatment arm: sarilumab 200mg if <75kg body weight or 400mg if ≥75kg body weight, corticosteriods plus soc for covid-19 -control arm: corticosteroids plus soc for covid-19. corticosteroids will be administered intravenously following this posology: methylprednisolone 1mg/kg/day (or equivalent cs doses) for at least 3 days plus soc according to local clinical practice protocols. study participants will be assigned using a central randomization service implemented in the ecrf. randomization codes will be provided by the cro and will be charged into the ecrf as to maintain the treatment concealment. the following assessments will be performed before study drug administration to confirm selection criteria: -vital signs including spo2 and tª -focused physical examination: including vital signs, weight, auscultation, signs of respiratory distress, and any other as clinically indicated -oxygen supplement requirements: type and fio2 -oxygen parameters: sao2, pao2 (if available), sao2 or pao2/fio2 clinical follow-up visits will be performed at 3, 5, and 15 days after treatment randomisation patients in soc group without sarilumab progressing to severe respiratory failure fulfilling criteria for treatment with anti-il6 inhibitors according to clinical practice guidelines, as defined by the presence of brescia-covid 2-3 plus inflammatory markers, will be rescued with sarilumab at the same doses and be included in an open-label phase. this group of patients will be followed up by two additional weeks after receiving sarilumab as recue medication (days 3, 5 and 15 following salirumab administration). patients randomly assigned to sarilumab therapy at baseline progressing to brescia-covid 2-3 will be rescued according to local clinical practice protocols. for all patients a final follow-up visit is planned at d28 from randomization, regardless of the initial treatment assigned. the following outcomes should be assessed: · pao2/fio2 index or spo2/fio2 index. · temperature ºc · chest radiography (at least one during the follow-up period, recommended between d3-5, unless medically indicated any other day as part of the routine care) · laboratory disease parameters (crp, d-dimer, il-6, ldh, lymphocite counts, ferritine, plus any routing laboratory determinations usually performed by the patients´s physicians) · death. · brescia-covid score · adverse events: adverse events (aes), serious aes, and laboratory abnormalities from the signature of the informed consent form or oral consent documentation, where appropirate. at inclusion they will be collected from the beginning of sarilumab administration. aes will be documented as per the national cancer institute's common terminology criteria for adverse events (ctcae) version 5.0 (appendix 4). if the patient has been discharged, they will be contacted by phone. if possible, a visit will be scheduled to complete the evaluation. at any time during the study, the patient may be seen in clinic for a visit outside of the protocolspecified visit schedule. selected tests as required may be performed at the discretion of the investigator team. the frequency of clinical visits could increase if deemed necessary because of clinical situation, incapacity or demands of the patient. in the event that a study subject leaves the study early (i.e., early termination) and additional visit will be obtained with additional testing as indicated at the discretion of the principal investigator. the principal investigator may decide to conduct final analysis of study data at any time, even while some subjects may remain in long-term follow-up. this decision may also take place after all the primary endpoint is the proportion of patients progressing to severe respiratory failure (brescia-covid ≥2), icu admission, or death. 10. proportion of patients showing more than >1 organ failure, e.g. cardiovascular, liver and kidney failure 11. safety and tolerability -adverse event: the occurrence of treatment adverse events (aes), serious aes (saes), and laboratory abnormalities in the following, but not limited to, parameters: acute phase reactants crp and esr, complete blood count (including anc and platelets), liver enzymes (alt, ast and ap), and lipid levels, (time frame: up to day 15) safety will be evaluated through the collection of all ae for up to 28 days. the principal investigator may decide to conduct interim analysis of study data at any time, even while some subjects may remain in follow-up. the timing of data analysis is the prerogative of the principal investigator, regardless of continuing long-term follow-up of study subjects. all adverse events will be recorded in the crf and graded according to the nci-ctc v.5.0 (see appendix 4). adverse event is defined as any event that results in worsening of the health of the subject of the clinical trial, regardless of relationship to the experimental therapy. it can be any symptom, sign, illness or experience, including abnormal results of diagnostic procedures, that develops or worsens in severity during the course of the study. any medical condition that is present at the time that the subject is screened will be considered as baseline and not reported as an ae. however, if the severity of any pre-existing medical condition increases, it should be recorded as an ae. given the nature of severity of the underlying illness, subjects will have many symptoms and abnormalities in vitals and laboratory. only grade 3 and 4 aes will be captured as aes in this trial, according to the following classification: · mild (grade 1): events that are usually transient and may require only minimal or no treatment or therapeutic intervention and generally do not interfere with the subject's usual activities of daily living. · moderate (grade 2): events that are usually alleviated with additional specific therapeutic intervention. the event interferes with usual activities of daily living, causing discomfort but poses no significant or permanent risk of harm to the research subject. the concept "life-threatening" means that in the opinion of the investigator, the patient is in real danger of death in the ae situation; it does not mean that the ae could have caused death if it would have been more intense. any ae that constitute an important medical event, will be treated as a sae regarding notification procedures. important medical events are those that may jeopardize the subject, and may require intervention to prevent one of the other serious outcomes noted above. all proven incidents of transmission of an infectious agent through the delivery of experimental therapy will also be reported as saes. adverse reaction is any untoward medical occurrence associated to the administration of a research drug. it is different to an ae in that, in the ar, there is a suspicion of causal relationship between the research drug and the effect. for each reported adverse event, the pi or designee must assess the relationship of the event to the study product using the following guideline: · related -the ae is known to occur with the study intervention, there is a reasonable possibility that the study intervention caused the ae, or there is a temporal relationship between the study intervention and event. reasonable possibility means that there is evidence to suggest a causal relationship between the study intervention and the ae. · not related -there is not a reasonable possibility that the administration of the study intervention caused the event, there is no temporal relationship between the study intervention and event onset, or an alternate aetiology has been established. the relationship or causality of the ae to sarilumab therapy will be determined by the pi of the center, or the person in whom she/he delegates. a susar is a serious adverse reaction (sar) as noted above, that is also unexpected. unexpectedness is defined as an adverse event in which the nature, severity, specific or consequences have not been previously observed or noted in the reference information for the drug or that has been noted in the same drug class. an adr with a fatal outcome is considered unexpected. all ae will be documented, including the ones observed during clinical visits and the ones reported by the patient. aes will be documented throughout the duration of the trial. the patient should be asked about possible aes in the time between clinical visits. all ae will be documented in the crf and in the medical records. all ae will be followed until resolution, until 15 days after the administration of the first dose of sarilumab (v1), or until toxicity is considered non-reversible or is grade 1. the patients who will participate in this study have a poor prognosis, with the possibility of death due to the disease. this possible progression is included in the primary endpoint, so it will not be necessary to report deaths as sae in this study. this event will be documented in the medical history and in the crf of the patient. the rest of the sae will be reported by the investigator following the expedited report procedure as follows. in case of occurrence of a sae that must be reported to pharmacovigilance, a sae serious adverse events reporting form must be completed and signed by the investigator within 24 hours. the investigator will keep a copy of this sae form on file at the study site. when additional information about the sae becomes available, or when the sae is resolved, or when any change is unexpected, the investigator must provide further information in the form of a written narrative that should also be sent to pharmacovigilance. the responsible will review the received form and will ask for additional information if needed. in the event of susar, follow-up information will be provided. sae appearing more than 15 days from the end of the experimental therapy will be reported if the investigator considers there is a causal relationship to the therapy or if it is of medical importance. all laboratory results must be filed in the subject's medical record and be monitored. the investigator must review laboratory results in a timely manner demonstrated by signature/date and assignment of clinical significance assessment. laboratory abnormalities that are not clinically significant, i.e., minor deviations from the normal range, are expected and it is likely that no medical intervention will be required. such results will not be considered to be adverse events. all ctcae grade 3 and 4 laboratory result abnormalities and any laboratory abnormality that is considered to be clinically significant by the investigator will be recorded on the ae case report form. an abnormal test result will be considered an ae if: · it is not associated with an already reported ae, diagnosis or pre-existing condition · there is a change in concomitant medication or intervention as needed, in direct response to the grade 3 or 4 laboratory result · the investigator exercises his/her discretion to make significance determinations for any subject laboratory result · all such laboratory abnormalities will be repeated and assessed as soon as possible for "seriousness" by the investigator or licensed physician, and if they meet the regulatory definition of "serious", they will be reported as saes following regulatory and protocol requirements. repeat laboratory tests may be run in order to monitor the result. any laboratory abnormality meeting the regulatory definition of "serious" must be recorded both on the adverse event case report form and the serious adverse event form. if a subject experiences a serious toxicity or dies, the local and national required regulatory authorities will be notified within 24 hours of awareness of the event, as required. responsible pharmacovigilance person will notify all susar to the aemps following the procedures approved by law. any susar will be reported within 15 calendar days from the moment when the sponsor has knowledge of it. any fatal or life-threatening, susar, should be reported within 7 days of the moment the sponsor had knowledge of it. the initial information should be completed, if possible, within 8 additional days. urgent notification to aemps (área de ensayos clínicos de la subdirección gral. de medicamentos de uso humano), will also be employed for all the information that could modify the risk-to-benefit balance of the experimental therapy or advice changes in the therapy, or in the trial. regulatory authorities will be notified of the new information will be notified as soon as possible and no later than 15 days from when the investigator has knowledge of it. additional information will be provided also as soon as possible. all susar and saes reported will be notified to the aemps and the ceim in an annual safety report. the statistical analysis will be carried out in accordance with the principles specified in the international conference on harmonization (ich) topic e9 (cpmp / ich / 363/96)1. a detailed statistical analysis plan (sap) agreed upon by the ct executive board and the project statistician will be available early during the recruitment phase. this sap will follow the general regulatory recommendations given in the iche9 guidance, as well as other specific guidance on methodological and statistical issues2. also, it will stick to the recommendations given by the consensus documents of the scientific journals3,4 to improve reliability and value of medical research literature by promoting transparent and accurate reporting of clinical research studies. the sas system5 (release 9.4, or an upgraded version), or equivalent validated statistical software, will be the statistical software used to analyse the data sets. a summary of the overall approach to statistical analysis is presented hereafter. to obtain a power of 80.00% to detect differences in the contrast of the null hypothesis h₀: p1 = p2 by means of a bilateral chi square test for two independent samples, taking into account that the level of significance is 5.00%, and assuming that the proportion in the reference group is 25.00%, the proportion in the experimental group is 10.00%, and that the proportion of experimental units in the reference group with respect to the total is 50.00 % it will be necessary to include 100 experimental units in the reference group and 100 units in the experimental group, totalling 200 experimental units in the study. the data review (dr) will be performed before lock of database. data will be examined for compliance with the trial protocol by the monitor and the data manager. deviations will be sent to the project statistician to plan listings for the data review (dr). the objective is to carry out the population selection and definition of the final study populations as well as a preliminary assessment of the quality of the trial data. there will the following analysis populations for this study: 1. full analysis set (fas): all patients who are randomized into the study will be included in the fas population. 2. per protocol population: per protocol (pp) patient sets will be defined as those patients included in the fas set without major protocol deviations that might impact the study's main assessments. these deviations will be assessed during the data review prior to database lock. 3. the safety population is defined as all randomized participants who received the investigational product. the precise reasons for excluding participants from each population will be fully defined and documented independently of the randomization codes during the data blinder review and before data lock. randomisation codes were produced by means of the proc plan of the sas system, with a 1:1 ratio of assignment between both arms, stratifying by centre, blocks multiple of 2 elements. the randomisation schedule will be managed from the ecrf in a concealed manner. a descriptive analysis will be performed for all parameters overall and by arm at every study timepoint. categorical parameters will be presented by means of frequencies and percentages. continuous parameters will be summarized by means of the appropriate descriptive statistics (mean ± standard deviation or median and interquartile range). the efficacy and safety endpoints will be descriptively compared between study arms. changes from baseline, when applicable, will also be summarized by study arm. the inferential analyses will be limited to the efficacy variables, and the adverse events. the primary endpoint is the proportion of patients progressing to severe respiratory failure (brescia-covid ≥2), icu admission, or death. the proportion of patients with failure at day 7, will be estimated using a log-binomial regression model including stratification variables. in the unexpected event that the model does not fit, the poisson regression model with long-link and robust variance estimator will be used instead. binary efficacy and safety outcomes will be analysed as described for the primary endpoint. the median of the absolute values the 95% confidence interval (95%ci) will calculated using the hodges-lehmann methods (i.e. median of all cross differences between treatments based on the mann-whitney distribution). continuous variables will be analysed using mixed models, including in the model the baseline measurement, the stratification variables, treatment as well as the interaction between treatment and time, declaring time as categorical. the variance-covariance matrix will be fixed initially as unstructured. contrasts between study groups will be performed by time-point. the treatment effect will be estimated through adjusted means -least square means (lsmeans) -its standard error -standard error of mean (sem)-and its 95%ci. differences between treatments will be estimated through the differences between lsmeans, sem and 95%ci. the survival function as well as the median [95% confidence interval -95%ci-] time to event will be estimated by means of the kaplan-meier method. group comparisons will be done using the (stratified) log-rank test and the (stratified) hazard ratios -hr-(95%ci) were taken from the cox model. the rest of variables will be analysed according to the following strategy: the fisher's exact test used for categorical variables, the t-test for gaussian distributed variables and, for non-gaussian continuous or ordinal variables, non-parametric methods (mann-whitney test). the study will end when all patients have been recruited, the last patient has completed the study procedures, and all queries and aes have been solved. the sponsor can terminate prematurely the study. the reasons to terminate prematurely or suspend a trial include, but are not limited to: -finding of unforeseen risks for the patients that are considered unacceptable -there is evident that the recruitment of patients is not adequate in number or quality. -incorrect data collection -ae rate or severity points to a safety risk in all the previous situations, a final evaluation of the patients included in the study should be made, and the crf will be completed, as much as possible. all deviations from the planned analysis would be reflected in the final report of the study. there will the following analysis populations for this study: 1. full analysis set (fas): all patients who are randomized into the study will be included in the fas population. 2. per protocol population: per protocol (pp) patient sets will be defined as those patients included in the fas set without major protocol deviations that might impact the study's main assessments. these deviations will be assessed during the data review prior to database lock. 3. the safety population is defined as all randomized participants who received the investigational product. the precise reasons for excluding participants from each population will be fully defined and documented independently of the randomization codes during the data blinder review and before data lock. the handling of missing data will follow the principles specified in the ich-e9 and the cpmp/ewp/1776/99 rev1. guideline on missing data in confirmatory trials guidelines. in principle, the rate of missing data is estimated to be very low due to the type of endpoint, easily available with a fast-clinical assessment, so no impact is expected in the primary analysis. in any case, a very conservative strategy will be implemented consisting of imputing any missing data or other binary efficacy secondary outcomes will be considered to failures, irrespectively to the reason for missingness. this study will be conducted in full conformance with the ich e6 guideline for good clinical practice and the principles of the declaration of helsinki, or the local laws and regulations. the investigator will be familiar with the use of the experimental therapy as described in the protocol. essential clinical documents will be kept to prove validity and integrity of data. essential files of the trial will be defined at the beginning of the trial, and kept during and after it, following current laws. a research ethics committee (rec) will review and approve this protocol, associated informed consent documents, prior to the recruitment, screening, and enrolment of subjects. any amendments to the protocol or consent materials will be approved by the rec before they are implemented. informed consent is a process that is initiated prior to an individual agreeing to participate in a trial and continuing throughout the individual's trial participation. investigators will obtain the subject's informed consent in accordance with the rd1090/2015, 4 de diciembre, por el que se regulan los ensayos clínicos con medicamentos, and the internationally accepted guidance. subjects will receive a concise and focused presentation of key information about the clinical trial. due to paper handling limitation in covid wards, oral witnessed consent will be accepted before entering into the trial. written consent form will be obtained from the patient himself or acceptable representatives whenever possible. the key information about the study will be organized and presented in lay terminology and language that facilitates understanding why one might or might not want to participate. participants will be assigned a unique identifier. any participant records or datasets that are introduced in the ecrf or transferred outside the clinical site will contain the identifier only; participant names or any information which would make the participant identifiable will not be transferred. the participant must be informed that his/her medical records may be examined by monitors, clinical quality assurance auditors or other authorized personnel appointed by the sponsor, by appropriate ceim members, and by inspectors from regulatory authorities. the data must be collected and processed with adequate precautions to ensure confidentiality and compliance with applicable data privacy protection laws and regulations (reglamento (ue) 2016/679 and ley orgánica 3/2008). trial medication will be provided by the sponsor who has obtained an agreement with sanofi to obtain free of charge medication supply. the sponsor will not finance the procedures that would be done as standard of care nor other medical needs of the patient, not related to the trial. this is a low intervention clinical trial and therefore there is no need to specific insurance covering legal responsibility for trial-related injuries. according to rd 1090/2015, any damage to study subjets suffered as a result of the trial will be covered by the professional civil liability insurance or equivalent financial guarantee of the site where the clinical trial is conducted.notification to health authorities this trial needs a request to agencia española de medicamentos y productos sanitarios (aemps) for approval. the trial need the approval before starting. the investigator will conduct the trial according to the protocol, after the approval of competent authorities and ceim. protocol will not be modified without approval of sponsor and competent authorities. all protocol amendments require previous approval of ceim with the exception of situations where the change is necessary to avoid immediate risk for the patient. if any change is needed to avoid imminent risk to the patients, the investigator will contact the sponsor to propose the changes. any deviation to the protocol should be documented and the original records. this study may be prematurely terminated if there is sufficient reasonable cause, including but not limited to: • determination of unexpected, significant, or unacceptable risk to subjects • results of interim analysis • insufficient compliance to protocol requirements • data that are not sufficiently complete and/or not evaluable if the study is prematurely terminated, the site pi will inform study subjects and the rec as applicable. the sponsor will notify regulatory authorities as applicable the principal investigator and the sponsor will guarantee direct access to all data and source documents as needed for monitoring of the trial as well as audit and review by ceim and health authorities. must agree with the present protocol and have a deep knowledge of the characteristics of the products used in the trial. the investigator should present the patient information sheet to the patients and help them to understand the explanation given. is important to explain to the patient that the participation is voluntary, that his/her decision will not affect to the relationship between patient and doctor and that all person involved in the study will respect the confidentiality of the information. the principal investigator his/her co-worker will collect, document and properly report the data. the principal investigator will be responsible of the urgent reporting of saes and susars within 24 h. principal investigator will inform the ceim about the evolution and will cooperate with the sponsor in the final report. clinical site monitoring is conducted to ensure that the rights and well-being of trial subjects are protected, that the reported trial data are accurate, complete, and verifiable. clinical monitoring also ensures conduct of the trial is in compliance with the currently approved protocol/ amendment(s), ich, gcp, and with applicable regulatory requirement(s) and sponsor requirements. monitoring visits will include, but are not limited to, review of regulatory files, accountability records, crfs, icfs, medical and laboratory reports, site study intervention storage records, training records, and protocol and gcp compliance. the monitoring visits can be made online. the investigator will permit study-related monitoring, audits, and inspections by the ceim, the sponsor, government regulatory bodies, and quality assurance groups of all study related documents. the sponsor is cristina avendaño sola, md, phd, medical staff at clinical pharmacology department, hospital universitario puerta de hierro. the sponsor is responsible for the initiation, management and termination of the trial. the sponsor is responsible for securing agreement from all involved parties to ensure direct access to all trial-related sites, source data/documents, and reports for the purpose of monitoring and auditing by the sponsor, and inspection by domestic and foreign regulatory authorities. the sponsor is responsible to ensure that trial is conducted and data are generated, documented (recorded), and reported in compliance with the protocol, gcp, and the applicable regulatory requirement(s). the investigator will permit study-related monitoring, audits, and inspections by the ceim, the sponsor, government regulatory bodies, and quality assurance groups of all study related documents (e.g. source documents, regulatory documents, data collection instruments, study data, etc.). the investigator will ensure the capability for inspections of applicable study-related facilities (e.g. pharmacy, diagnostic laboratory, etc.). the study results may be published in scientific journals, or presented at scientific meetings by the investigator following agreement of the sponsor with sanofi, the manufacturer and provider of sarilumab, with mention of the ceim that approved the study. the study results will be subject to the terms agreed by the sponsor and sanofi in the investigator initiated research agreement signed in relation to this study. will be filled on the electronic clinical trial platform by the investigator team from the original data source of the clinical record of the patients. the investigator will keep all the original documents of the clinical records for each patient and a list of all the patients included for 25 years or until an agreement with the sponsor. this documentation will not be destroyed without the sponsor agreement. the investigator will custody all the files in agreement with the international conference on harmonisation (ich) the investigator and institution will maintain the essential trial documents in the trial master file (tmf) as specified in the gcp guidelines (ich:e6: section 8.0) and as required by the applicable regulatory requirement(s). the investigator/institution should take measures to prevent accidental or premature destruction of these documents. the sponsor will assign monitoring personal to the trial. his roles will include helping the investigator and the sponsor to keep data well organized and easy to access. coronavirus infections and immune responses covid-19 illness in native and immunosuppressed states: a clinical-therapeutic staging proposal effective treatment of severe covid-19 coronavirus infections and immune responses covid-19 illness in native and immunosuppressed states: a clinical-therapeutic staging proposal effective treatment of severe covid-19 patients with tocilizumab tratamientos disponibles para el manejo de la infección respiratoria por sars-cov-2. aemps link acute respiratory distress syndrome advances in diagnosis and treatment risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease clinical predictors of mortality due to covid-19 based on an analysis of data of 150 patients from wuhan, china clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study immunotherapeutic implications of il-6 blockade for cytokine storm a-at least one radiographic assessment will be conducted during the follow-up visits, initially scheduled at d3 visit or d5 visit, unless otherwise medically indicated b-valid any imagin available up to 96h prior to randomisation c-a complete laboratory parameters assessment should be available within 24 hours prior to randomisation d-an additional blood sample will be collected and stored at huph biobank for future studies clinical data collection x x x x x physical examination x x x x brescia-covid scale x x x x vital signs: spo2 /tª x x x x mechanical ventilator requirement x x x x mortality x x x x ae /sae reporting x x x x x key: cord-031315-p7jb4gf2 authors: kong, qing; mo, shuming; wang, wenqian; tang, zihui; wei, ying; du, yijie; liu, baojun; kong, lingwen; lv, yubao; dong, jingcheng title: efficacy and safety of jia wei bushen yiqi formulas as an adjunct therapy to systemic glucocorticoids on acute exacerbation of copd: study protocol for a randomized, double-blinded, multi-center, placebo-controlled clinical trial date: 2020-09-03 journal: trials doi: 10.1186/s13063-020-04669-5 sha: doc_id: 31315 cord_uid: p7jb4gf2 background: systemic glucocorticoids are effective for the management of chronic obstructive pulmonary disease (copd) exacerbation but have serious adverse effects. traditional chinese medicine (tcm) can bring additional benefits to these patients but has few adverse effects. the present study aims to evaluate the efficacy and safety of jia wei bushen yiqi (jwby) formulas in patients who suffer from copd exacerbations and to investigate whether the short-term (5-days) systemic glucocorticoid therapy is non-inferior to the long-term (9-day) regime. methods: in this multi-center, randomized, double-blinded trial, eligible inpatients with copd exacerbation are randomly assigned to four groups (a, b, c, and d). group a will receive placebo plus 5-day prednisone, group b will receive placebo plus 9-day prednisone, group c will receive jwby formulas plus 5-day prednisone, and group d will receive jwby formulas plus 9-day prednisone. the primary outcomes are the time interval to the patient’s next exacerbation during a 180-day following up and the copd assessment test (cat) during treatment. secondary outcomes include lung function, tcm syndrome assessment, laboratory tests, and safety. the changes of the hypothalamic pituitary adrenaline axis (hpa axis) and inflammatory cytokine will be measured as well. discussion: by demonstrating the advantages of utilizing tcm and an appropriate duration of systemic glucocorticoids, this effectiveness comparison trial will provide new references to physicians on how to improve the management of copd exacerbation. the results of hpa axis and inflammation cytokine measurements will shed light on the molecular mechanisms and entail further mechanism studies. trial registration: www.chictr.org.cn chictr1900023364. registered on 24 may 2019. chronic obstructive pulmonary disease (copd) will become the third leading cause of death worldwide in 2030 [1] . 13 .7% of the population over 40 years old suffer from copd in china [2] , creating a large socioeconomic burden [3] [4] [5] . copd exacerbation is defined as the acute worsening of respiratory symptoms that require additional therapy [6] [7] [8] . acute exacerbations of copd impair pulmonary function and exponentially increase the risk of death [9] . therefore, effective management of copd is critical to human health. according to international guidelines and evidencebased reviews, systemic glucocorticoids are recommended to treat copd exacerbation [10] [11] [12] [13] [14] [15] . the advantages include shortened recovery time and hospitalization duration, improved lung function and oxygenation, and reduced relapse risk and treatment failure, which have been demonstrated by numerous randomized clinical trials (rct) [16] [17] [18] [19] [20] [21] [22] . however, the side effects like hypertension, hyperglycemia, gastrointestinal bleeding, psychiatric disease, and hypothalamic pituitary adrenal axis (hpa axis) suppression increase with the extension of treatment duration and the escalation of dose [23] . controversy over the optional duration continues. on one hand, a dose of 40 mg prednisone (a common oral systemic glucocorticoid) daily for 5 days has been recommended by the global initiative for chronic obstructive lung disease (gold) science committee report based on the reduce randomized clinical trial since 2015 [24] . the trial indicated the efficacy of 5-day systemic glucocorticoids is noninferior to 14-day systemic glucocorticoids regarding relapse within a 6-month follow-up, but significantly reduced glucocorticoid exposure. on the other hand, a dose of 30-40 mg prednisone daily for 9-14 days [10, 12, 13] was suggested by another academy of china, korea, and europe in 2017. yet, no clinical trials have determined the difference between the 5-day and 9-day regimes. in addition, treatment individualization brings benefits. for instance, an inhaled corticosteroid (ics) is more efficacious in patients with high blood eosinophils [25] [26] [27] . however, present pharmacotherapy has failed to reverse the downtrend in pulmonary function completely [28] . hopefully, traditional chinese medicines (tcm) can expand copd treatment in terms of syndromic difference, also called zheng [29] . not only has tcm alleviated symptoms such as coughing, shortness of breath, and sputum for thousands of years, but also has demonstrated its efficacy and safety [30] [31] [32] [33] [34] . however, there are rarely studies focused on copd patients during the acute exacerbation period, most of them focused on the relatively stable period. we conducted a randomized and placebo-controlled trial enrolling stable copd patients in 2014, which illustrated that tcm formulas called bushen yiqi (by) formulas can improve the lung function, reduce the frequency of acute exacerbation of copd, and modulate the hpa axis [35] . dr. shen replaced glucocorticoid therapy with tcm formula (by) totally in chronic inflammatory disease [36] . moreover, several ingredients in by can decrease the inflammatory reactions in copd animal models [37] . recently, we have observed that by formulae combined with another two chinese herbs-huang qin (scutellaria) and chi shao (paeoniae rubra radix)-demonstrate more effectiveness on the management of acute exacerbation of copd in clinical practice, such as relieving the symptoms including the cough, sputum, as well as shortness of breath. interestingly, the laboratory experiments showed that the main compound of these two chinese herbs benefits the animal of copd model. for instance, scutellaria baicalensis in huang qin significantly improved lung function, ameliorated the pathological damage, and attenuated inflammatory cytokines infiltration into the lungs [38] . similarly, paeonol in chi shao showed antiinflammatory and antioxidant effects against cs-induced lung inflammation in both in vivo and in vitro experiments [39] . therefore, we propose that jia wei bushen yiqi formulae (jwby)-bushen yiqi formulae combined with huang qin and chi shao-will benefit patients with acute exacerbation of copd. this study aims to demonstrate non-inferiority of a 5-day therapy compared with a 9-day regimen of systemic glucocorticoids based on the copd outcome during the 180-day follow-up period. it also seeks to determine the relative inferiority of jwby formula as an adjunct treatment to systemic glucocorticoids compared with systemic glucocorticoids alone for copd exacerbation. this is a multi-center, double-blinded, placebocontrolled, randomized clinical trial. this trial will be conducted in two stages: a 9-day treatment and then a 180-day follow-up. qualified patients will be randomized to 4 groups: group a will receive placebo plus 5-day prednisone, group b will receive placebo plus 9-day prednisone, group c will receive jwby formulas plus 5day prednisone, and group d will receive jwby formulas plus 9-day prednisone. assessments will be performed on day 6 and on day 10 during treatment and telephone calls will be conducted on day 90 and on day 180 when patients are discharged (fig. 1) . the 9 day-treatment is chosen for two reasons. first, it is because of the two aims that were mentioned above. second, the 9-day treatment period is based on our investigation result that most copd exacerbation symptoms can be alleviated within 10 days. in other words, 9 days are the common hospitalization time in ten subcenters. therefore, the 9 day-treatment is a good time for patients to complete the study during hospitalization, which will promote the compliance of patients and collect as much data as possible. the 180-day follow-up time is based on the results from the reduce randomized clinical trial research published on jama in 2014. it is reported in this trial that the median number of days of follow-up was 180 in both the conventional group (10th percentile, 179; 90th percentile, 181 days) and in the short-term treatment group (10th percentile, 178; 90th percentile, 181 days). this trial will be conducted at ten hospitals located in shanghai, yunnan, xinjiang, and jiangsu province in china. five hospitals are selected because they are attached to universities and another five hospitals are selected because they are experienced in rct. also, these hospitals are spread out throughout china ( table 1 ). the principal investigator (pi) work at huashan hospital and is responsible for the steering committee meeting, which includes protocol training, supervision of safety, quality control, feedback of progress, and study reports. pis of other hospitals will organize their clinical physicians and nurses to carry out recruitment and follow-up. patients that are hospitalized with copd acute exacerbation and meet the inclusion and exclusion criteria ( table 2) will be eligible to be study participants. acute exacerbation of copd with clinical grade 2 is defined as follows: respiratory rate > 30 times/min, application of assisted respiratory muscles, no mental state change, hypoxemia can be improved by the 25%-30% oxygen concentration in the inner cover of the venturi, and hypercapnia or partial pressure of carbon dioxide (paco 2 ) increases to 50-60 mmhg from the baseline value. patients who are diagnosed as having respiratory failure but without the risk of death are appropriate for ordinary hospitalization, as recommended by the chinese expert consensus on the diagnosis and treatment of acute exacerbation of chronic obstructive pulmonary disease (aecopd) (2017 update) [10] . in other words, a moderate degree of copd exacerbation does not indicate the need for intensive care unit (icu) admission according to 2019 gold guideline [24] . tcm syndrome differentiation-fei_shen_qi_xu_yu_ re zheng in chinese-specifies people who have lung and kidney qi deficiency mixed with blood stasis and (table 3) . study centers are selected from level a hospital in china. the investigators will be selected from attending physician who majors in respiratory disease. prior to the trial, all sub-center physicians, nurses, and other staff will be trained to understand the protocol. attending physician who will take charge of the patients obtains consent from potential participants or authorized surrogates. firstly, attending physician will introduce the trial including the origin of tcm formula, the prednisone effect, what they should do, and what will benefit them if they volunteer to participate in this trial. then, physician will reply to the questions that confuse patients. finally, both the physician and patient will sign the informed consent form to indicate the patient's full understanding of the protocol. in the consent form, participants will be asked if they agree to use of their data should they choose to withdraw from the trial, and if they are volunteer to provide another 25 ml blood for storage, which are used to explore their inflammation level, hpa axis function, and the relationship between effectiveness and gene type. participants will also be asked for permission for the research team to share relevant data with people from the hospitals who take part in the research. as we mentioned in background, prednisone of 30-40 mg once daily is recommend for copd exacerbation management since 2014 by golg guideline. the evidence is from a clinical trial that compare the efficacy of 14 days of prednisone treatment with 5 days. the participants come from sweden. as in other countries like china, the duration of prednisone treatment is recommended as 9-14 days. the differences of the outcomes between 5 days of treatment and 9 days are unknown in the chinese patients. since we choose the relatively mild patients with copd exacerbation, the minimum dose of prednisone 30 mg once daily is decided in this trial. in addition, tcm formula has been used for copd therapy for thousands of years. we have observed the superiority of tcm as an adjunct therapy in copd administration. but there is no evidence to show the exact outcomes. the doses of five tcm herbs are decided by a group of experienced tcm physician who used the principle of tcm in treating copd for many years. the control group is placebo that contains 10% true herbs with the same appearance and smelling as the drugs. severe impairment of heart, liver and kidney function (heart function 3-4 degree, aspartate aminotransferase (alt) and/or alanine aminotransferase (ast) exceeds 1.5 times of the upper limit of normal, creatinine (cr) exceeds the upper limit of normal) 6 . received systemic glucocorticoids within 2 weeks or participation in other drug clinical trials within 3 months prior to the trial 7. other conditions that the investigators consider to be improper all the participants will be provided with standard of care (soc) according to the 2019 gold guideline for copd exacerbation during hospitalization and after discharge (table 4) . a 9-day adjunct medication includes systemic glucocorticoids and tcm herbs or their placebo. a basic dose of 30 mg prednisone daily for 5 days will be provided for all participants. the prednisone will be continued in the long-term glucocorticoids arm of the trial in the following 4 days and replaced with the placebo in short-term glucocorticoids arm of the trial. the 9-day treatment period is based on the fact that most copd exacerbation can be relieved within 10 days. meanwhile, participants will be treated with tcm herbs or placebo. participants will be randomized to four groups with different adjunct medication ( fig. 1) . because of the complex and variety in copd exacerbation, variation among patients will be allowed. any variation like another antibiotic used for the indication will be recorded in the case report form (crf). tcm treatment is in accordance with the most common tcm syndromes of copd in a real-world study [40] . the dosage of jwby formula is selected according to the pharmacopeia of chinese medicine, and the effective ingredient of its granules is determined according to the pharmacopeia of pharmacopeia. jwby formulas contain 5 kinds of herbs: huang qi (astragalus) 30 g, yin yang huo (epimedy) 20 g, sheng di huang (radix rehmaniae) 15 g, chi shao (red peony) 30 g, and huang qin (scutellaria) 30 g, concentrated as 20.48 g granules. to use, patients can infuse 10.24 g granules into 125 ml of boiling water and ingest orally after breakfast and supper, twice daily. its placebo is identical in appearance, shape, size, and package with jwby formulas, but only contains 10% real herbs. the granules will be produced and packed by huarui sanjiu pharmaceutical industry in shenzhen, china. granule production will be certified to get the standard certification of the tcm national drug regulatory authority. modification or discontinuation of the intervention will be decided by the pis in each center, according to the requests from participants, or when a participant's disease is worsened to grade 3 which indicates the need for icu admission, or when unexpected adverse effects happen. prednisone and jwby granules are free as study drugs. five-day drugs will be provided to participants at baseline by a sub-center investigator and another 4-day drug at day 6. participants will use patient diaries for recording medication and changes in symptoms. all unused packs of drugs and empty bags will be returned to investigational site on day 6 and on day 10. compliance will be calculated by counting drugs or empty bags for a 9day course. compliance % of medication = [actual dose/ (specified daily dose × days)] × 100%. total medication consistency ranging from 80 to 120% will be eligible for the protocol analysis set. patients enrolled in the trial will be all hospitalized and all the laboratory tests will be performed on standard schedule, which aids in the monitoring of adherence. once the patient is randomized, the investigators will take every reasonable effort to follow the patient for the entire course of the study. all examination and transportation costs in the 30-day will be covered and the results of symptoms and physical exams will be explained at every visit. messages will be sent through wechat or by phone prior to every visit to remind the patients of the follow-up visits. extra copd-related drugs, such as leukotriene receptor antagonists, antihistamines, immunosuppressants, and antioxidants, will be forbidden during the trial. tcm herbs that are tonifying kidney, benefiting qi, clearing away heat, and promoting blood circulation, whose tcm characteristics are like those within jwby formulas, will be avoided. drug combinations will be recorded in the case report form at each follow-up visit. "tonifying kidney" ("bushen" in chinese) is a tcm term of treatment, which aims at the tcm syndrome "deficiency of kidney" ("shen_xu" zheng in chinese). the chinese herbs used in "tonifying kidney" treatment can relieve "deficiency of kidney" syndrome including shortness of breath, deterioration with movement, fatigue, waist and knee area sore, and their weakness, tinnitus, dizziness, incontinence, or heavy urine volume. patients that are enrolled into the study will be covered by indemnity through the standard national health service indemnity arrangements. the pi will provide the compensation to those who suffer due to trial participation. primary outcomes measurements 1) the time to the next exacerbation of copd during the 180-day follow-up is defined as one primary outcome. the definition of exacerbation is deterioration of the cardinal symptom of dyspnea, increased sputum purulence and volume, and purulent sputum. this may be combined with one of the other symptoms: increased cough and wheeze, sore throat, nasal congestion due to cold, fever (oral temperature > 37.5°c), increased cough, and increased wheezing. the above changes should last for ≥ 2 days at least. a minimum of 1 week between two exacerbations is needed in order for them to be considered as separate events. the duration of exacerbation is measured from the onset of acute exacerbation to a significant reduction which is defined as the symptoms return to the level before the exacerbation per the records in patients' dairies. the diaries are distributed to participants during the treatment and after the treatment. participants record changes of their symptoms and their health status by choosing the right description in terms of feeling. the primary symptom is measured with modified british medical research council (mmrc) and copd assessment test (cat) scores. the days of exacerbation are calculated from the onset date of the primary symptom to the date when all symptoms disappear. the degree is classified as mild (treated with short acting bronchodilators only, sabds), moderate (treated with sabds plus antibiotics and/or oral corticosteroids), or severe (patient requires hospitalization or visits to the emergency room). severe exacerbations may be associated with acute respiratory failure. 2) the mean difference of cat scores between day 6 or day 10 and baseline is another primary outcome. the cat involves an 8-dimension measurement of health-status impairment in copd. cat is universally acknowledged as a reliable and valid measurement in evaluating the changes of copd. 1) tcm syndrome assessment will be evaluated from baseline to day 6 and day 10. according to the guiding principles for clinical research of new drugs in traditional chinese medicine, the syndrome score is calculated as efficacy index n = (pre-treatment score − post-treatment score)/ pre-treatment score × 100%. in terms of mild, moderate, and severe symptoms, the primary symptoms are given 2, 4, and 6 points while the secondary symptoms are given 1, 2, and 3 points respectively. total score = scores of the primary symptoms + scores of the secondary symptoms. 2) lung ventilation function will be assessed by forced expiratory volume in 1 s (fev1), forced vital capacity (fvc), and peak expiratory flow (pef) from baseline to day 6 and day 10 with standardized equipment (erich jaeger uk ltd., market harborough, uk jaeger master-screen, germany) and per the standard procedure recommended by american thoracic society (ats) [39] . 3) blood gas analyses including partial pressure of oxygen (pao 2 ), partial pressure of carbon dioxide (paco 2 ), infectious indexes including blood eosinophil count in cells per micrometer (eos), creactive protein (crp), and proclamation will be tested by clinical laboratories in the sub-center from baseline to day 6 and day 10. side effects will be collected at day 30, day 60, and day 180 during follow-up. this specifically refers to (1) the changes in hyperglycemia: fasting plasma glucose ≥ 5.6 mmol/l or random plasma glucose ≥ 7.8 mmol/l or rise ≥ 20% in daily doses of insulin or any increase in oral anti-diabetic drugs or initiation of one or more antidiabetic therapeutics, (2) changes in hypertension: systolic blood pressure ≥ 140 mmhg and/or diastolic blood pressure ≥ 90 mmhg or the addition of one or more anti-hypertensive drugs to previous treatment regimens, and (3) the number of psychiatric symptoms, asphalt, vomiting coffee samples, and new infection. laboratory tests which include routine blood test, routine urine test, electrocardiogram (ecg), kidney and liver function, and x-ray computed tomography (ct scan/x-ray) of the chest will be conducted at baseline, day 10, and day 30 during the follow-up. if the results of ct scan/x-ray and ecg are normal at baseline, it will be skipped in the follow-up. the pathology of copd is relevant to the inflammation and the suppression of the hpa axis that follows the treatment with glucocorticoids. therefore, changes in the hpa axis including corticotropin-releasing hormone (crh), adrenocorticotropic hormone (acth), and cortisol and the inflammation cytokines including interleukin-6, interleukin-8, and interleukin-10 at baseline and on day 6 and day 10 will be measured. there are four groups with two variables in this trial-tcm treatment and systemic glucocorticoid treatment. therefore, according to primary endpoints collected from previous trial [34, 41] , we choose the maximum sample size needed, as calculated by two way on http:// www.powerandsamplesize.com (table 2 ). at the 5% significance level, a total of 67 patients per group will be required for a 2-group, 1-sided calculation to achieve 80% power and the differences of 10.30 ± 6.31 and 12.95 ± 5.99 in cat mean score between the tcm treatment group and placebo group (table 5) . meanwhile, a total of 88 participants will be required for a 2group non-inferiority calculation to achieve the mean difference of the time to next exacerbation (43.5, 29) and a non-inferiority margin of 10, under the condition that the standard deviation of the groups is equal to 12 (table 5) . a loss of 15-20% to follow-up is predicted based on experience-this increases the sample size to 200 participants per group, resulting in 400 in total. all investigators in the sub-center will advertise and distribute posters in their emergency department and nearby communities. in addition, we will set up a hierarchical medical system in shanghai-communities refer the potential patients to huashan hospital directly where the clinical trial is undertaken. participants will be randomized with equal probability (1:1:1:1) to receive one of the four treatments that were mentioned above. as the size of each group is predicted to be 100, the allocation sequence is generated with sample randomization and stratification by trial center. the sequences will be generated by software and in excel format. before the study begins, a series of random numbers will be generated by the computer, and the pharmacists involved in the study place the random numbers in plain, closed envelopes marked with patient numbers. envelopes will be made and stored at the pharmacy and opened by the pharmacist only when the subjects are randomized. the envelopes will be not accessible to individuals directly involved in the study. allocation sequence will be generated by a statistician who will not participate in enrolling participants. participants will be blindly randomized and allocated with an identified number. principal investigators including attending physician and nurses will involve in enrolling participants. pharmacist will distribute an independent emergency envelope for each participant, which contains the treatment assignment. the participants in the placebo group will be given the same number of pills and followed the same medication schedule as the treatment group. to ensure the implementation of the blinding method, the pill and herbs in both the treatment group and the placebo group will be made in the same shapes, smells and tastes. trial participants, care providers including attending physician and nurse, outcome assessors including pi and sub-pi, and data analysts will be blinded after the assignment of interventions. double-grade unblinding will be adopted. first grade unblinding: it will be conducted before the data analysis. after the double input of all the crf data into the computer and blinded review, the data will be locked. afterwards, the personnel who keep the blinded materials will unblind them for the first time, which is to divide the groups corresponding to the case numbers into blinded codes of two groups and to tell the statisticians so as to statistically analyze all the data. second grade unblinding is after the statistical analysis and the completion of clinical trial report. it will be conducted at the wrap up meeting for the clinical trial. the treatment group and control group will be unblinded. place of unblinding will be the unit where the clinical trial is in charged. executive personnel will be the chief researcher and statisticians of the unit that are in charge of the trial. if there is severe adverse event, which impedes the progress of the trial and the selection of the treatment measures, urgent unblinding can be carried out. during the process, all the researcher, sub-pi, and clinical supervisors should take part. the local administrative unit should be informed within 24 h. the reason, time, and place of unblinding should be recorded in detail and all the records should be signed off. afterwards, the clinical supervisors should be informed timely. the case data should be kept intact. prior to the start of the trial, sub-center physicians will be trained. the results of laboratory tests from different hospitals are adjusted per the huashan hospital standards during analysis. demographic information (date of birth, gender, etc.) and medical condition (medical history, concomitant medication, etc.) will be recorded at baseline. all the questionnaires will be answered by patients without inducement. when adverse events that are related to study drugs happen, emergency envelope can be considered as needed to be opened by pis and physician. the investigators will report the reasons and outcome to the pi within 24 h. prior investigation shows that the mean hospitalization duration time is about 8-9 days in these 10 hospitals, which matches the trial requirement of 9 days of treatment. after screening and completing baseline evaluations, participants will visit the physician at day 6 and day 10 during adjunctive treatments and day 30 when patients are discharged (fig. 2) . we will provide free tcm granules and partial examination reimbursement to participants. the participants and their family member will be informed that standardized treatment is beneficial to reduce copd exacerbation, which will reduce medical expenses the benefits. two telephone calls will be conducted on day 90 and day 180. the writing and transfer of case report the case report will be written by the doctor who has participated in the trial. every case should have a complete case report. the case report, once completed, should be checked by the supervisor. afterwards, it will be transferred to the data administrator for data entry and management. all the information in crf table will be recorded in a specialized clinical experimental database that is designed by chinese academy of traditional chinese medicine. the format of the database should be close to that of the crf table so as to facilitate the data entry. the variables in the crf table will be encoded and the codes will be kept unchanged during the whole process of clinical research. the crf data will be entered by highly trained specialists from the research centers. the audit of data can be divided into two forms: manual audit and system audit. the former refers that the administrator checks the consistency and logic of the data so as to find the mistakes and to generate the question list. sas software sets the limit of all variables and rules out automatically the unqualified data by running the system program. the question list is sent to the clinical supervisor who transfers it to the researcher for reconfirmation. the related revision should be signed and dated by the researcher. the researcher will correct the data for the last time after the return of all question lists. all the corrections and updates should be recorded and filed. after the data is verified, the data administration meeting will be held so that the corrections and updates can be summarized. at last, the data administrator will announce the locking of database and keep the cipher code. the statistical analysis prospectus will not be changed after the database lock. the data will be transferred to the statistical department for analysis. all the data should be kept according to the requirements of gcp. after the experiment, all the original copy of case reports and records for the administrations of clinical drugs should be checked, signed, and stamped by the supervisors, head researchers, and representatives from gcp office of each clinical center, and finally, these records will be sent to the leading site where the database will be established and the data will processed. statisticians will analyze the data and materials from the participating centers, and the summary of the clinical trial will be completed in the leading site. case report form (crf) collects all the information throughout the trial for every participant. as soon as verification is completed, data will be securely stored and sent to huashan hospital from the sub-centers. a data management group will be established, and the information will be entered into the database provided by http://www.rilintech.comt through independent doubledata entry. the errors and inconsistencies of data will be checked during the entry process. the user identification code and password will be protected by the data management group. the pis will be given access to the cleaned data sets. sub-investigators will only have access to the data sets in their own hospital. original paper forms will be kept in huashan hospital for 5 years. plans for collection, laboratory evaluation, and storage of biological specimens for genetic or molecular analysis in this trial/future use {33} the process and collection of blood samples separation of 1-2 ml of plasma from 4 ml of whole blood the anticoagulant and aprotinin (for concentration and amount, please refer to the note) will be added to the blood-collection tube, which is placed at 4°c for precooling, and then1.5 ml of whole blood will be collected. the samples will be mixed in the tube slowly, and afterwards, the mixture will be centrifuged at a low temperature (4°c, 4000 r/min, 15-20 min). 0.5 ml of plasma will be collected and kept at a low temperature (− 80°c). if the collected blood cannot be centrifuged immediately, it can only be stored in 4°c freezer for up to 1 h. note: the concentration and amount of anticoagulant and aprotinin. anticoagulant: 0.3medta.2na concentration (20ul/ ml) or 1% heparin (10ul/ml); aprotinin (500 iu/ml). there are two kinds of aprotinin: liquid (the concentration will be noted on the label) and solid (10,800 iu/mg). the solid form of aprotinin can be dissolved in normal saline, so its concentration can be adjusted to 500 iu/20 μl. requirements for sample storage the samples should be kept immediately in − 80°freezer. throughout the transportation, the samples cannot be taken out. in huashan hospital, all of the samples are checked. the samples should be labeled with case codes and collection date. blood serum should be kept in dry ice for transportation. primary and secondary outcomes the tcm intervention arm-jwby (jia wei bushen yiqi formulas)-will be compared against the placebo. the short-term systemic glucocorticoid (ssg) arm will be compared against the long-term systemic glucocorticoid (lsg) arm. four groups will be compared with each other independently. statistical package for social sciences for windows, version 24.0 (spss, chicago, il, usa) will be used for analysis. the tests will be 2-sided, and a p value with alpha ≤ 0.05 level is considered significant. p values will be reported to four decimal places with p values less than 0.001 reported as p < 0.001. the bonferroni method will be used to appropriately adjust the overall level of significance for multiple comparisons, assuming an exchangeable correlation structure. categorical variables will be summarized by absolute numbers and percentages of total. the difference of categorical variables will be assessed with the generalized estimating equations (gee). gee will also be used to assess the impact of potential clustering of participants in the same hospital. safety outcomes will be analyzed with summary statistics (frequency, count, percentage). the method of analysis of each variable are summarized in table 6 . the score of copd assessment test (cat) will be collected at baseline, day 6, day 10, and in the 30 days, 90 days, 180 days after discharge. the mixed effect normal model (menm) will be used to compare each outcome against the tcm intervention group and placebo. the estimate of treatment effect will be presented as unadjusted rate ratio followed by an adjusted ratio with adjustment for a set of pre-specified baseline variables. the list of pre-specified variables is as follows: centers (as a random effect), age (in years), gender (male or female), weight (in kilogram), smoking (pack per year), fev1% predicted, the number of copd exacerbation in the previous 1 year, and home-oxygen therapy. fixed effects will include the visit number, treatment, and all the prespecified variables. participant and visit interaction will be fitted as random effects. an autoregressive correction structure will be used throughout. the difference of interval time to next exacerbation during follow-up in the 30 days, 90 days, and 180 days will be compared between ssg and lsg groups using the generalized linear model (glm) with a log-link function, a propriety over dispersion parameter, and length of time as an offset. the numbers will be described respectively in three gradesoutpatient, inpatient, and icu. durations of copd exacerbation will be compared between each two of the four groups with glm in the similar manner as before. specially, the shortness of breath measured by mmrc dyspnea scale (1-5 degree) in the diary will be undertaken in the logit link function independently. the changes in tcm syndrome score, infectious index, lung function, blood gas analysis, inflammatory cytokine levels, and hpa axis will be collected in baseline, at day 6, and at day 10. glm will be used to analyze the change between each two of the four groups as well. none. in this trial, interventions for participants include 9 days of tcm granules and 5 or 9 days of prednisone. these two interventions will be carried out during hospitalization and they are routine treatments in china, so there are no anticipated problems that will be detrimental to the participant. therefore, there will be no interim analyses and there are not anticipated formal stopping rules for the trial. methods for additional analyses (e.g., subgroup analyses) {20b} subgroup analysis the potential subgroups have been listed in table 3 . the analysis of primary outcomes will be repeated in the subgroups. methods in analysis to handle protocol non-adherence and any statistical methods to handle missing data {20c} analysis will be in accordance with the intent-to-treat principles. the safety set (ss) includes participants that are randomized and have received adjunct treatments and one post-treatment safety assessment at least. the full analysis set (fas) includes participants that are randomized and have received adjunct treatment, and their primary outcomes are available at least in one visit. the per protocol set (pps) includes participants in accordance with all the following conditions: valid baseline values, compliance with the program, no violation of the inclusion and exclusion criteria specified in the program, completion of all assessments, and good compliance (defined as participants taking at least 80% of expected doses of study drugs as determined by counting). missing data is predicted to appear on day 30 and during the two telephone calls after discharge. the imputation of all the outcomes will be replaced by the mean of the group. plans to give access to the full protocol, participant level data, and statistical code {31c} full protocol participant level dataset in chinese will be accessible in the register site. and statistical code will be provided by trial statistician. for sharing purpose, data will be available to outside investigators at the end of the trial. the finding of this trial will be published in peerreviewed journals and presented at conferences. the results of the study will be released to the participating physician and patients. composition of the coordinating center and trial steering committee {5d} multi-center trial coordination committee will be established. the huashan hospital affiliated to fudan university will take charge of the committee, and the main researchers of the participating units will serve as the members. the committee will be responsible for the implementation of the whole experiment and resolve problems during the trial process. the head researcher should strengthen quality surveillance of the clinical trial in his own center. composition of the data monitoring committee, its roles and reporting structure {21a} the data monitoring committee is unnecessary in this trial, because the drug duration in this trial is short-9 days. tcm granules and prednisone are routine treatment in china and will be carried out during hospitalization; only minimal risks are anticipated. adverse event report regardless of whether it is related to the study drug or not, any clinically significant abnormalities of medical events or laboratory tests will be defined as an adverse event (ae). for all adverse events, the time, duration, treatment measures and outcomes, the severity of the disease, and the association with the study drug will be evaluated and recorded. it is divided into mild, moderate, and severe according to the following list: conscious symptoms, ability to tolerate, impact on daily activities, duration, whether it is relieved during continued medication, and whether treatment is required. serious adverse events (sae) will be defined as death or life-threatening events. if a sae occurs, the doctor will immediately take emergency measures and report it to the pi and the ethics committee within 24 h. according to the occurrence of adverse events and a reasonable time interval, and alleviation after withdrawal of the study drugs, the correlation between adverse events and study drugs will be evaluated as affirmative (sure), probably related (very likely), may be relevant (possible), may be unrelated (suspicious), and irrelevant (impossible). due to the unsatisfactory treatment effect, the patient will withdraw from the trial. the emergency letter of the case will be opened, and the patient's family will coordinate with the follow-up and report the result to the lead center. the relevant information will be recorded in the case report form. although the formula is optimized to instant granule instead of tcm herbs decoration in our study, some participants who never accepted tcm herbal previously may have gastrointestinal reactions such as nausea and vomiting. they will be suspended for 3 days and evaluated on their abilities to continue to participate in. because the participants are in the acute exacerbation period, their disease may deteriorate to grade 3 at any time with the worsening of clinical symptoms including increase of dyspnea, mental consciousness changes, blood gas analysis of acidosis, and hypoxemia that cannot be improved by oxygen absorption or other treatments. participants will be admitted to the intensive care unit (icu) if it happens. due to the worsening of the disease or the unsatisfactory effect, the emergency letter of the case will be opened. the physician-incharge will communicate with the patient's family if participant needs to withdraw from the study. the relevant information is reported to pi and recorded in the case report form. as for any deterioration syndromes that arise after discharged, participants will be advised to come to the hospital. the investigator will provide free medical services appropriately. the recommend dose of prednisone by 2017 chinese consensus is 30-40 mg daily for 9-14 days. the low dose of 30 mg is chosen. extra management measures were suggested during the initial meeting. first, the participants will be informed that the withdrawal symptoms include fatigue, joint muscle soreness, low mood, poor appetite, and even nausea and vomiting. second, participants discharged from the hospital with adrenal insufficiency will receive instructions on how to take less than 30 mg daily if they cannot tolerate the treatment. finally, participants will be advised to take the following preventive measures against possible adverse events. closely and modulate the number of hypoglycemic agents or insulin. 2) investigators will pay attention to whether the patient has abdominal pain, vomiting of coffee-like substances, or tar-like black stool. if this occurs, the patient should promptly come to the emergency department and be treated with acid-suppressing stomach and other drugs. 3) investigators will observe the patient's neuropsychiatric symptoms closely, such as euphoria, excitement, mania, and insomnia. if necessary, advise patients to seek medical help. the designated monitor will visit each investigational site once a month. the monitor will check that if the regulatory binder is complete and all that associated documents is stored well or not, including crf, informed consent forms, and adverse events reports. and the monitor will help the investigational site resolve the issues happened in the trial. plans for communicating important protocol amendments to relevant parties (e.g., trial participants, ethical committees) {25} any modification to the protocol which may impact the conduct of the study and the potential benefit of the patients will be reported to ethic committee. the amendments will be approved by the ethics committee before it is announced to each investigational site. and an investigator training about new protocol will be held through wechat video meeting. participants will be informed of the new protocol. participant information will not be released outside of the study without the permission of individuals except for monitoring. blood samples, data collection, and administrative forms will be identified with the same code and stored separately in a locked place. all data will be uploaded to the resman original data sharing platform (ipd sharing platform) http://www.medresman. org of the china clinical trial registry, which is available to outside investigators when the trial ends. the result will be published in peer-reviewed journals and shared at conferences. the findings of the trial will be released to the participating physicians and patients. with the design of tcm as an adjunct to systemic glucocorticoids to treat copd exacerbation in this randomized trial, we will test the non-inferiority of two different treatment terms of systemic glucocorticoids in copd exacerbation. the finding will bring new proofs to the controversial applications of glucocorticoids. in addition, we will clarify a pragmatic method to identify the efficacy of classic description based on tcm syndrome differences despite limitations like bias of measurement and the subjectivity of the questionnaire assessment which may be exacerbated by the loss of some participant during follow-up. the difference between the four groups will indicate that tcm reduces the suppression of the hpa axis and strengthens the anti-inflammation effect of glucocorticoids. tcm may strongly support and enrich the management of copd exacerbation. however, there are some limitations in this protocol. firstly, we choose one of the specific tcm syndromes as the criteria. the result is hard to be extended to the whole patients with copd exacerbation. in addition, we use the chinese guideline to evaluate the degree of copd exacerbation, which relies on the subjective assessment of symptoms of the enrolled participants by the physician. hopefully, an objective method will be proposed to assess the copd exacerbation. our trial has enrolled 10 volunteers in shanghai from 07 august 2019 up to today. we have modified protocol according to the practice and standard protocol items [42, 43] . in the meantime, we proposed amendment to ethics commitment and chinese clinical trial registry in july of 2019. the protocol version is ky 2019-299,03,03, july, 2019. the new protocol was reported to all subcenter pis in a group meeting. due to covid-19, we expect to complete the recruitment process around october 2020 and report the results as soon as possible. supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04669-5. additional file 1. burden of copd prevalence and risk factors of chronic obstructive pulmonary disease in china (the china pulmonary health cph study): a national cross-sectional study prevention and management of copd in china: successes and major challenges chronic obstructive pulmonary disease in china: a nationwide prevalence study mortality, morbidity, and risk factors in china and its provinces, 1990-2017: a systematic analysis for the global burden of disease study international variation in the prevalence of copd (the bold study): a population-based prevalence study copd exacerbations: defining their cause and prevention symptom variability in patients with severe copd: a pan-european cross-sectional study acute copd exacerbations expert consensus on acute exacerbation of chronic obstructive pulmonary disease in the people's republic of china treatment with systemic steroids in severe chronic obstructive pulmonary disease exacerbations: use of short regimens in routine clinical practice and their impact on hospital stay copd clinical practice guideline of the korean academy of tuberculosis and respiratory disease: a summary diagnosis, prevention and treatment of stable copd and acute exacerbations of copd: the swiss recommendations use of glucocorticoids in patients with copd exacerbations in china: a retrospective observational study controlled trial of oral prednisone in outpatients with acute copd exacerbation oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease oral or iv prednisolone in the treatment of copd exacerbations -a randomized, controlled, double-blind study efficacy of corticosteroid therapy in patients with an acute exacerbation of chronic obstructive pulmonary disease receiving ventilatory support systemic corticosteroids in acute exacerbation of copd: a metaanalysis of controlled studies with emphasis on icu patients prednisone in copd exacerbation requiring ventilatory support: an open-label randomised evaluation global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease: the gold science committee report 2019 susceptibility to exacerbation in chronic obstructive pulmonary disease acute exacerbations of chronic obstructive pulmonary disease identification of biologic clusters and their biomarkers blood eosinophils to direct corticosteroid treatment of exacerbations of chronic obstructive pulmonary disease: a randomized placebo-controlled trial effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of fev (1) -the lung health study zheng: a systems biology approach to diagnosis and treatments oral chinese herbal medicine for improvement of quality of life in patients with stable chronic obstructive pulmonary disease: a systematic review efficacy and safety of indacaterol 150 and 300 mu g in chronic obstructive pulmonary disease patients from six asian areas including japan: a 12-week, placebo-controlled study bu-fei yi-shen granule combined with acupoint sticking therapy in patients with stable chronic obstructive pulmonary disease: a randomized, double-blind, double-dummy, active-controlled, 4-centre study effects of comprehensive therapy based on traditional chinese medicine patterns in stable chronic obstructive pulmonary disease: a four-centre, open-label, randomized, controlled study effects of yupingfeng granules on acute exacerbations of copd: a randomized, placebo-controlled study effects of two chinese herbal formulae for the treatment of moderate to severe stable chronic obstructive pulmonary disease: a multicentre, double-blind, randomized controlled trial important action of improving adrenocortical function for certain diseases recovery effect and mechanism of several traditional chinese medicine components on inflammatory response of chronic obstructive pulmonary disease caused by exposure to cigarette smoke scutellaria baicalensis attenuates airway remodeling via pi3k/akt/nf-kappab pathway in cigarette smoke mediated-copd rats model paeonol attenuates cigarette smoke-induced lung inflammation by inhibiting ros-sensitive inflammatory signaling a real-world evidence study for distribution of traditional chinese medicine syndrome and its elements on respiratory disease short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the reduce randomized clinical trial spirit 2013 statement: defining standard protocol items for clinical trials spirit 2013 explanation and elaboration: guidance for protocols of clinical trials publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank dr. yiyuan zeng and dr. waijiao cai from school of public health, boston university, for their linguistic assistance during the preparation of this manuscript. qing kong and shuming mo drafted the manuscript. wenqian wang, zihui tang, baojun liu, yijie du and lingwen kong participated in the design of the study. zihui tang participated in the statistic plan. ying wei, yubao lv and jingcheng dong conceived the study, participated in its design and coordination, and drafted the manuscript. all authors read and approved the final manuscript. all named authors adhere to the authorship guidelines of trials; no professional writers have been involved. the enrolled participants who sign the informed consent forms about clinical data and bio-sample collection are provided with free medication of jwby formulas and prednisone for 9 days as needed. participants' information will not be released outside of the study without the permission of individuals except for monitoring. blood samples, data collection, and administrative forms will be identified with the same code and stored separately in a locked place. all data will be uploaded to the resman original data sharing platform (ipd sharing platform) http://www.medresman.org of the china clinical trial registry, which is available to outside investigators when the trial ends. the result will be published in peer-reviewed journals and shared at conferences. the findings of the trial will be released to the participating physicians and patients. central ethics committee approval has been obtained from ethics committee of huashan hospital affiliated to fudan university in shanghai, china (id: ky-2019299). the local ethics committee of other ten hospitals has approved the protocol, too. the trial was registered on www.chictr.org.cn (id: chictr1900023364) on may 24, 2019. the investigator will make safety and progress reports to the ethics committee monthly. protocol amendment will be approved by the ethics committee prior to the implementation of amended protocol at the sub-centers. all investigators are trained to carry out the new protocol. there is no conflict of interests among the subcenters. informed consent will be obtained from all study participants. these are available from the corresponding author upon request. there are no competing interests in this work.author details key: cord-253129-v5lck9l7 authors: kim, kyeong tae; morton, sophie; howe, sarah; chiew, yeong shiong; knopp, jennifer l.; docherty, paul; pretty, christopher; desaive, thomas; benyo, balazs; szlavecz, akos; moeller, knut; shaw, geoffrey m.; chase, j. geoffrey title: model-based peep titration versus standard practice in mechanical ventilation: a randomised controlled trial date: 2020-02-01 journal: trials doi: 10.1186/s13063-019-4035-7 sha: doc_id: 253129 cord_uid: v5lck9l7 background: positive end-expiratory pressure (peep) at minimum respiratory elastance during mechanical ventilation (mv) in patients with acute respiratory distress syndrome (ards) may improve patient care and outcome. the clinical utilisation of respiratory elastance (cure) trial is a two-arm, randomised controlled trial (rct) investigating the performance of peep selected at an objective, model-based minimal respiratory system elastance in patients with ards. methods and design: the cure rct compares two groups of patients requiring invasive mv with a partial pressure of arterial oxygen/fraction of inspired oxygen (pao2/fio2) ratio ≤ 200; one criterion of the berlin consensus definition of moderate (≤ 200) or severe (≤ 100) ards. all patients are ventilated using pressure controlled (bi-level) ventilation with tidal volume = 6–8 ml/kg. patients randomised to the control group will have peep selected per standard practice (spv). patients randomised to the intervention will have peep selected based on a minimal elastance using a model-based computerised method. the cure rct is a single-centre trial in the intensive care unit (icu) of christchurch hospital, new zealand, with a target sample size of 320 patients over a maximum of 3 years. the primary outcome is the area under the curve (auc) ratio of arterial blood oxygenation to the fraction of inspired oxygen over time. secondary outcomes include length of time of mv, ventilator-free days (vfd) up to 28 days, icu and hospital length of stay, auc of oxygen saturation (spo(2))/fio(2) during mv, number of desaturation events (spo(2) < 88%), changes in respiratory mechanics and chest x-ray index scores, rescue therapies (prone positioning, nitric oxide use, extracorporeal membrane oxygenation) and hospital and 90-day mortality. discussion: the cure rct is the first trial comparing significant clinical outcomes in patients with ards in whom peep is selected at minimum elastance using an objective model-based method able to quantify and consider both inter-patient and intra-patient variability. cure aims to demonstrate the hypothesized benefit of patient-specific peep and attest to the significance of real-time monitoring and decision-support for mv in the critical care environment. trial registration: australian new zealand clinical trial registry, actrn12614001069640. registered on 22 september 2014. (https://www.anzctr.org.au/trial/registration/trialreview.aspx?id=366838&isreview=true) the cure rct clinical protocol and data usage has been granted by the new zealand south regional ethics committee (reference number: 14/sth/132). mechanical ventilation (mv) support is crucial for patients with acute respiratory distress syndrome (ards). while there is agreement on the preference for lower tidal volumes [1, 2] , there is relatively little consensus on the selection of positive end-expiratory pressure (peep) [3] [4] [5] [6] [7] [8] [9] . traditionally, lower peep has been used [10, 11] , but low peep can lead to increases in oxygen desaturation and hypoxaemia [4, 12] and worsening of lung injury, indicated by greater use of rescue therapies and deaths after rescue therapy [9] . high peep can increase alveolar recruitment, but can decrease cardiac output and lead to further lung injury due to barotrauma and/or volutrauma [13] or overdistension [4, 9] . peep can be optimised to reduce hypoxaemia [6] and intrapulmonary shunting [7] and improve gas exchange [8] and oxygenation [4, 14, 15] , by maintaining recruitment of injured or collapsed alveoli [13] . in patients with ards, peep reduces ventilator-induced lung injury (vili) [4, 9] , increases recruitment [14] [15] [16] , and reduces inflammatory mediators in plasma and bronchoalveolar lavage fluid [8] . mv strategies combining low tidal volumes with recruitment manoeuvres (rms) and higher peep to prevent vili have been hypothesized as ideal for lung protection [6, 17] . however, currently, there is still no standardized approach to the selection of this optimal peep, or to deciding how often peep should be adjusted or recalculated. reports from experimental animal trials performed by carvalho et al., suarez-sipmann et al. and lambermont et al. [18] [19] [20] indicate that pigs induced with ards experience minimal respiratory elastance at a specific peep associated with higher oxygenation, maximum recruitment, and higher functional residual capacity, all without signs of lung overdistension. equally, it has been proposed that peep should be set whereby the lung has minimal respiratory elastance (or maximum compliance), which could be clinically beneficial by balancing the risks of peep that is set too low or too high [21] [22] [23] . aside from the work by suter et al. [21] , pintado et al. also showed that peep selection at minimal elastance is beneficial to patients [22] . despite some consistent findings, the application of minimal elastance peep selection remains limited and hindered by the lack of an objective, reliable, and easy-to-use method to determine elastance at the bedside in real time. chiew et al. showed the potential benefit of minimalelastance peep selection in a pilot study [23, 24] . following the study, a phase-2 randomised controlled trial (rct) was designed to assess mechanical ventilation at minimal elastance peep in patients with ards versus standard practice of care in a single-centre hospital. in particular, patientspecific respiratory system elastance and corresponding minimal elastance peep is determined using a validated model-based method and computer software [25] . this trial uses real-time-identified patient-specific respiratory system elastance, and thus the trial is named the clinical utilisation of respiratory elastance (cure) rct. this manuscript presents the detailed clinical protocol for the phase-2 cure rct. this trial is registered with the australian new zealand clinical trial registry (anzctr): actrn12613001006730. the cure rct is a two-arm rct comparing modelbased mechanical ventilation (mbv) with current standard practice mechanical ventilation (spv) in patients with a ratio of partial pressure of arterial blood oxygen (pao2)/fraction of inspired oxygen (fio2) (p/f ratio) ≤ 200. it is to be conducted in a single-centre hospital intensive care unit (icu) at christchurch hospital in christchurch, new zealand. the primary objective is to assess the impact of model-based ventilation in peep selection (mbv) therapy on clinically significant patient outcomes and patient-centred quality of care metrics. the other objectives of this study include (1) to provide the knowledge and methods to make care more patient-specific and timely to optimise treatment and improve outcomes in a large cohort of critically ill patients and (2) to improve the understanding of the pathophysiological basis of critical illness through what we learn about the hourly and daily evolution of lung injury in terms of patient-specific elastance and response to care through this study. the primary outcome of this study is the area under the curve (auc) of pao2/fio2 over the period of mechanical ventilation. secondary outcomes include length of time of mv (lomv), ventilator-free days (vfd) up to 28 days, icu and hospital length of stay (los), auc of spo 2 (oxygen saturation)/fio 2 during mv, number of desaturation events (frequency and fraction of time spo 2 < 88%), changes in respiratory mechanics and chest x-ray index scores, rescue therapies (prone positioning, nitric oxide use, extracorporeal membrane oxygenation (ecmo)) and hospital and 90-day mortality. these outcomes and their corresponding four levels of specification based on zarin et al., 2011 is shown in table 1 . the secondary analysis includes comparison of the means of lomv, vfd, hospital and icu los, 90-day mortality, chest x-ray index scores and rescue therapies used. a difference in primary and secondary outcomes will show the impact of mbv compared to spv. no difference would show that enhanced, model-based metrics of patient-specific condition have no effect on patientcentred or clinical outcomes. either outcome will yield clinical guidance. eligible patients are randomised to either the modelbased intervention group (mbv) or the control group (spv). both groups will have designated computer software to monitor their breathing [25] . the software uses real-time measurements of pressure and flow from the ventilator to objectively calculate the patient-specific and breath-specific respiratory system elastance for every breath [25] . participants on mbv will undergo recruitment manoeuvres (rm), an initial maximum recruitment manoeuvre (rm max ) or subsequent peep adjustment and monitoring procedure (pump) mini recruitment manoeuvres. the respiratory elastance at each peep step during these protocolised rms is calculated and recorded. the software will recommend a patient-specific minimal-elastance peep to the clinicians in setting ventilator peep. patients on spv will have peep selected using current clinical practice without the aid of the software, but all breaths will be analysed and elastance recorded; clinical staff will be blinded to these data. patients recruited into this study will be under constant supervision in the icu. however, their outcomes will be measured based on the intention-to-treat principle, taking into account protocol variations, which naturally occur. these variations will be reported to the primary investigator at the earliest opportunity and followed up. there will be detailed training on the use of cure equipment and on the protocol, to allow adherence to trial. this trial is based on the intention-to-treat principle. thus, protocol amendments may be required to ensure patient safety and outcomes, and the primary investigators will instigate protocol amendments if necessary. the amendments will be reviewed by the data monitoring committee (dmc) to warrant patient safety and outcomes. the dmc may also refer protocol amendments based on outcomes of the interim analysis reports. finally, if participant enrolment is slow, the protocol may be amended to allow faster recruitment. the trial involves critically ill participants who are mechanically ventilated. thus, it is likely and acceptable for participants to be receiving medication related to any other concomitant comorbid conditions while participating in the cure rct. participants in this study will not be concomitant to another study that would affect the results of this study. participants will not be co-enrolled in another study that uses different oxygenation settings, recruitment manoeuvre procedures or anything that may affect the outcomes of this study. the following are the cure rct inclusion, exclusion and p/f ratio criteria. the inclusion criteria are: i. on any level of peep or fio 2, or ii. p/f ratio ≤ 200 on fio 2 = 50% and peep = 5 (see "p/f ratio criteria") the exclusion criteria are: the p/f ratio criteria are: 1. if the p/f ratio is ≤ 200, the patient is eligible for enrolment 2. if 200 < p/f ratio ≤ 300, set fio 2 = 50% and peep = 5 cmh 2 o and repeat the analysis of arterial blood gases (abg) within 10 min of the change to measure the new p/f ratio a. if the new p/f ratio is ≤ 200, the patient is eligible for enrolment b. if the new p/f ratio is > 200, the patient is not eligible for enrolment and, if appropriate, will be re-screened at a later time this trial will recruit patients who have a p/f ratio ≤ 200, a criterion in the definition of severe to moderate ards as defined by the ards definition task force in the berlin definition [26] . they will be eligible if their p/ f ratio is ≤ 200 on any level of peep and fio 2 . those patients with a 200 < p/f ratio ≤ 300 will be placed on peep = 5 cmh 2 o, and fio 2 = 50%. if a subsequent p/f ratio is ≤ 200 they will also become eligible (see additional file 1). the p/f ratio measured at fio2 of 50% and peep of 5cmh 2 o is based on villar et al. 2013 [27] . first, it is important to note that standard ventilation practice may include recruitment manoeuvres to increase lung recruitment and oxygenation. however, these clinical practices are widely variable and often not standardised. the recruitment techniques used to improve oxygenation and mechanics of ventilation in the intervention and control arms of this study are within the scope of standard icu clinical practice. the protocols used will standardise these existing interventions to recruit lung volume and titrate peep. study participants will be unable to consent to participation in this study prior to enrolment as they will be sedated and mechanically ventilated. it is also equally important to randomise participants to either arm of the rct at the commencement of mv to ensure a fair comparison. patients who have been ventilated ≤ 48 h are eligible for the cure rct. given this time frame, the cure rct will recruit patients once family consent is obtained. however, if the treating clinician firmly believes a recruitment manoeuvre is in the best interests of the patient, and no family is available for consent, the participant will be enrolled and randomised and the appropriate protocolised recruitment manoeuvre will follow. in this case, delayed consent is obtained as early as possible. once the participant recovers from their condition and is discharged from the icu, we will seek their informed consent. in cases where the family cannot attend the hospital to sign a statement of assent, their opinion will be obtained by telephone in the first instance. information about the study will either be made available by emailing them the information sheet and contacting them later by telephone, or the information sheet will be read to them over the telephone. the telephone conversation(s) and their opinions will be documented in the patient's medical record. as soon as the family is able to attend the hospital, they will be asked to sign the statement. if the family are not able to sign a statement during the patient's time in the icu, they have the option of printing out the statement, signing it, and mailing, emailing or faxing it back. the sample study information and consent forms can be seen in additional file 2. if the participant's family, relative or friend does not agree to their continued participation, they will be withdrawn from the study and we will seek agreement from them to use information related to mechanical ventilation that was collected up until that point. if a participant chooses to withdraw from the trial, we also will seek agreement to use information related to mechanical ventilation that was collected up until that point. if they do not agree, then all study information obtained will be destroyed. participants will be block-randomised, with block sizes generated using a randomisation programme. the programme will randomly assign patients into either a control group or intervention group through a random block size (the block size is 4, 6, 8 or 10 patients). eligible and consented patients will be block-randomised in a ratio of 1:1. no effort will be made to stratify the subgroups considered in the secondary analyses. by the nature of the intervention, cure cannot be double-blinded. un-blinding is not applicable due to the nature and setting of the intervention. all patient data collected are de-identified using a single patient numbering system. patients are assigned to a study number to ensure no bias in the results. this system will be a simple incrementing scheme, such that patients randomised into the cure trial are identified as study-001, study-002, etc. the v t is adjusted to 6-8 ml/kg per ideal body weight (ibw), and the maximum minute ventilation (v emax ) to ≤ 0.2 l/kg/min. the ibw is measured using the patient's height and look-up table at the bedside or is calculated using the formulae: women the dp is the plateau pressure (p plat ) minus the peep. in patients with very severe ards the adjustment of v t to 6-8 ml/kg ibw may be injurious if the dp is higher than 15 cmh 2 o. a dp ≤ 15 cmh 2 o was associated with better patient survival when assessed using a multilevel mediation analysis of 3562 patients in nine rcts of ards [28] . therefore, the dp will be limited to ≤ 15 cmh 2 o at all times. in addition, during spontaneous ventilation, pressure support will be limited to ≤ 15 the ventilation rate is set between 12 and 20 breaths per minute. the aim is to keep the plateau pressure p plat ≤ 30 cmh 2 o. if necessary, v t may be reduced to as low as 4 ml/kg and the respiratory rate (rr) kept at ≤ 30 breaths per minute. co 2 will frequently rise in severe lung injury (permissive hypercapnia) when patients are mechanically ventilated within these guidelines. however, if co 2 is ≥ 80 mmhg or increased by ≥ 50% in the previous 4 h, the intensive care specialist on duty will be notified, and they may choose to deviate from these guidelines. all patients enrolled are to be ventilated using a pressurecontrolled mode, for example, the bi-level ventilation mode on the puritan bennett pb840 ventilator (covidien, boulder, co, usa) or pc-simv+ on the dräger evita® in-finity® v500. patients will be ventilated using bi-level/pc-simv+ mode, which allows unrestricted spontaneous breathing efforts to lessen ventilator dyssynchrony. however, during any recruitment manoeuvre procedures, synchronized intermittent mandatory ventilation (simv) with pressure-controlled (pc) ventilation is used and returned to original mode afterwards. should patients already be ventilated using a ventilator incompatible with the cure computer system, they will have their ventilator changed to a compatible ventilator for the trial. patients will be transitioned to assisted spontaneous breathing (asb) if they meet the weaning criteria (see "weaning"). in severe ventilator dyssynchrony, a very high respiratory drive may result in sub-atmospheric circuit pressures and risk of aspiration of gastric contents around the endotracheal cuff. if a participant has a high respiratory drive on bi-level/pc-simv+ ventilation, producing a fall in airway pressure during inspiration, muscle relaxants will be considered to facilitate controlled breathing. however, if the clinician feels the participant may benefit from breathing spontaneously, transition to asb may be made if they substantially meet the weaning criteria (see "weaning"). however, spontaneous breathing efforts may mask high trans-pleural pressures and produce high levels of regional lung strain. oesophageal pressure will not be measured during this trial. if the treating clinician is concerned about patient self-inflicted lung injury (p-sili) [29, 30] , they will consider using muscle relaxants to control ventilation. patients will not undergo any procedures using a cough-assist machine prior to weaning and transitioning to spontaneous breathing. however, the treating clinician may use a cough-assist machine to aid secretion removal (during spontaneous breathing) if they believe it is in the patient's best interests. finally, in any circumstances where the patient is planned to be temporarily disconnected from the ventilator, their endotracheal tube will be clamped to prevent de-recruitment. to ensure a fair comparison, all cure study participants will have inspired oxygen levels titrated to achieve the following pulse oximetry saturations: i. spo 2 = 93-95% if fio 2 is less than 60% ii. spo 2 = 90-92% if fio 2 is greater than or equal to 60% the aim is to spend greater than or equal to 90% of time in the target range. the fio 2 should only be increased above 21% if these targets are not met, using 5% increments starting with a fio 2 = 25%. there is natural variability in spo 2 . to avoid toggling between two fio 2 levels, 10 min of settling time will be allowed before changing the fio 2 . the best fio 2 is chosen to keep the saturation within the specified targets ranges over 90% of the time. patients are kept at 30°head up whenever possible. this position maximises recruitment of the lung and may reduce the risk of aspiration. wherever possible, patients should be rolled from supine to right-side down, back to supine, then to left-side down. this turning of patients is ideally performed every 3 h. transient hypoxaemia frequently occurs after a patient has been turned and may be worse if there is inadequate peep. hypoxaemia may also become more severe if participants are rolled from left-side down to right-side down due to cyclical de-recruitment of the non-dependent lung and re-recruitment of the dependent lung. this cyclical de-recruitment of the lung has the potential to contribute to vili. thus, patients with severe lung injury may be very intolerant of being turned. in some instances, the lungs may need to be re-recruited. if desaturation does occur, this will be recorded as a serious adverse event (sae). prone positioning of patients may be considered if the p/f ratio is ≤ 100 and fio 2 ≥ 60%. patients randomised to the intervention arm (mbv) may still undergo a protocolised recruitment manoeuvre. for patients in the standard practice ventilation arm (spv) a staircase recruitment manoeuvre is left to clinical judgement. the primary outcome of this trial is the auc of the p/f ratio. for this reason, mandatory daily abg recordings are performed for up to 10 days after enrolment. abgs are taken around 0600 hours and 1800 hours. the abgs are also acquired within 60 min of any recruitment manoeuvre procedure and 30-60 min after the recruitment manoeuvre procedure. the added abgs from rm procedures will be used in secondary analysis, but will be omitted during primary analysis to ensure the same number of data points per day for all patients. patients randomised to the model-based ventilation (mbv) cohort will remain in the protocol up to 10 days. thereafter, they will receive the same care as participants assigned to standard practice ventilation (spv). however, if participants have been extubated, but then require intubation and re-ventilation at any time within 10 days of enrolment, they will return to the original assigned protocol (mbv or spv). all patients will receive standard care beyond 10 days of enrolment, and their data, including abg recordings, will continue to be collected for up to 28 days. this intervention schedule is shown in fig. 1 . procedures for the control group (spv) the procedures are as follows: 1. peep is selected as per standard practice. 2. the decision to carry out a staircase recruitment manoeuvre will be based on clinical judgement. the protocol for performing the staircase recruitment manoeuvre is explained in "recruitment manoeuvres (rm)". 3. abgs will be taken twice daily. 4. ventilator data are collected continuously until the ventilator is disconnected. the procedures are as follows: 1. for patients included in the mbv (intervention) group, the peep and mv will be guided by clinicians using bedside computers, while maintaining v t and fio 2 . iii. when they have a new neurological condition. iv. they are awake and breathing normally without evidence of respiratory distress, and where sedation (with or without paralysis) is not considered to be in their best interests. 4. abgs will be recorded twice daily and before and after any recruitment procedure. 5. data will be collected continuously until the patient is disconnected from the ventilator. patients enrolled in this study will undergo rms. the rms are only carried out by senior medical staff or senior trainees familiar with this technique. rm max and pumps are for participants randomised to the mbv protocol arm only. patients assigned to the spv arm may undergo a staircase rm (srm) at the discretion of the treating clinician according to standard practice. (see "standard practice staircase recruitment manoeuvre"). all rms will be performed in simv pressure controlled (pc) ventilation mode. the peak inspiratory pressure (pi) is set to achieve a v t of 6-8 ml/kg ibw. preferably, v t should result in dp ≤ 15 cmh 2 o above peep. before and after each rm, abgs (ph, paco 2 , pao 2 , hco 3 ), spo 2 , end-tidal co 2 partial pressure (etco 2 ), fio 2 , peep, rr), and v t will be recorded. in addition, during the rm max (model-based ventilation arm) or (standard practice ventilation (srm) arm, at each peep increment, heart rate, rhythm, mean arterial pressure (map), spo 2 , fio 2 , v t , rr, etco 2 and rates of use of vasoactive drugs will be recorded. this data will be valuable in assessing the safety of the rm max , pump and srm. in many cases, where the lung stiffness, or respiratory elastance (e) is high, it will not be possible to deliver a v t of 6 ml/kg ibw. furthermore, during the rm, the delivered v t may fall further as the elastance increases. as a result, it may be necessary to increase the respiratory rate to accommodate the reduction in minute ventilation. for example, if e is > 40 cmh 2 o/l (or compliance < 25 ml/cmh 2 o) in a patient weighing 58 kg (ibw), (normal range 15-20 cmh 2 o/l), the v t will be < 6 ml/kg (< 350 ml) when the driving pressure is 15 cmh 2 o. it is important that oxygenation targets in both arms are carefully followed to ensure a fair comparison between them. the spo 2 will be kept in the target range prior to any rm. this approach allows small decreases in oxygenation to be detected during the decremental peep phase of the recruitment manoeuvre, while also providing a sufficient buffer in the event of significant de-saturation due to ventilation perfusion (v/q) mismatch. v/q mismatch increases with higher airway pressures when pulmonary arterial blood is shunted away from the pulmonary capillaries by-passing aerated regions of the lung. before performing any rm, the following criteria are considered. any rm must be delayed until these conditions are corrected in the consideration of the following at-risk patient conditions: 1. haemodynamic instability (e.g. ongoing haemorrhage). 2. not optimally resuscitated with fluids (e.g. stable blood pressure, but pulse pressure variation ≥ 12% because of inadequate left ventricular preload)? this is only applicable in the absence of spontaneous breathing. 3. evidence of barotrauma since enrolment? a. if there is new barotrauma, rms must not be attempted and the participant will be withdrawn from trial. they will continue to be observed and followed up. a sae will be reported. once the rm checklist conditions are met, the patient can be prepared for a rm by ensuring: rms should be terminated if at any time during the rm any of the following changes persist for more than 3 min: 1. desaturation, with spo 2 < 88%. 2. new bradycardia (heart rate < 60 beats per minute) or, 3. new tachycardia (heart > 140 beats per minute) or, 4. new arrhythmia leading to new bradycardia (2) or new tachycardia (3) or, 5. new hypotension (reduction in map by 40% or map < 60 mmhg). this rm termination criteria applies to all rm procedures in both arms. the rm max is a computer-guided staircase rm procedure in the mbv intervention arm. this method is designed to safely increase the inspiratory pressure to a maximum airway pressure of 40-43 cmh 2 o, with dp limited to 15 cmh 2 o, and maximum peep limited to 25-28 cmh 2 o. the rm max is guided by the cure software using a validated model-based method, which estimates elastance to determine the optimal peep [23, 31] . the rm max is carried out by intensive care specialists or senior trainees familiar with this technique. this procedure is only carried out during working hours (0800-1800 hours), but preferably within 4-6 h of enrolment. however, for patients enrolled overnight, unless there are compelling reasons to carry out an rm max , this procedure may be delayed till the following morning (0800 hours). contra-indicated preconditions to an rm max are excluded using the rm checklist. if it is safe to proceed, the patient is prepared for the rm max . the following instructions are given to the clinician: the rm max may be repeated only when the following conditions are met: 1. if there is a significant change in the participant's condition, e.g. new severe hypoxaemia (spo 2 < 90% and fio 2 ≥ 60%; p/f~100) and 2. patient conditions for which lung recruitment is contraindicated are excluded (e.g. endobronchial intubation, mucous plugging, pneumothorax etc) and 3. analgesia and sedation and patient position have been optimised (consider small changes to respiratory rate, v t and pressure support, or a rocuronium infusion) and 4. the pump fails to improve oxygenation pump: peep adjustment and monitoring procedure pump is a regular mini-recruitment manoeuvre procedure designed to adjust peep based on patient-specific changes in condition. this mini-rm is also guided by cure software and moves between ±4 cmh 2 o from the current peep. pump should be performed twice daily during normal working hours (0800-1800 hours) or at any other time if lung de-recruitment is considered to be the likely cause of new desaturation. the pi will be left the same as in the current ventilator settings. to ensure a pump can be safely carried out, the rm checklist and preparation steps are to be followed. if the checklist preconditions are met, the pump may be carried out. the following instructions are given to the clinician: 1. titrate sedation so the patient is not verbally responsive and has loss of their eyelash reflex. use fentanyl or morphine increments with propofol to provide a "balanced" deeper sedation level. give rocuronium 0. if the oxygenation does not improve with the aforementioned interventions, then peep may be increased in increments of 2 cmh 2 o. if the peep is ≥ 15 cmh 2 o and fio 2 is ≥ 60%, (p/f~100) in spite of addressing the aforementioned points, a staircase recruitment manoeuvre (srm) may be considered if the clinician feels this is in the best interests of the patient. the srm procedure does not utilise the cure software to perform recruitment and therefore the software will not guide the user, nor make any peep suggestions. the software will still record airway pressure and flow through this procedure. to ensure a srm, can be safely carried out, the rm checklist and preparation steps are to be followed. if the checklist preconditions are met, the srm may be carried out (note, the srm procedure does not utilise cure software to perform recruitment). the following instructions are given to the clinician: 1. titrate sedation so the patient is not verbally responsive and has loss of their eyelash reflex. use fentanyl or morphine increments with propofol to provide a "balanced" deeper sedation level. ventilator dyssynchrony occurs when a patient's spontaneous respiratory efforts are not synchronised with the ventilator. this commonly causes agitation and respiratory distress; often described as "fighting the ventilator". dyssynchrony should be considered in patients with increased respiratory efforts, unexplained agitation, tachycardia, or sweating. ventilator wave forms can be used to identify dyssynchrony. in participants assigned to mbv, dyssynchrony will often cause large spikes in the elastance recordings. the cure soft algorithm does not account for patient breathing efforts and "sees" inspiratory effort as a rapid reduction in lung elastance [32, 33] . in contrast, coughing, breath-holding, and other dyssynchronous efforts may cause an apparent increase in elastance [34] . figure 2 shows an example of ventilator dyssynchrony in a pressure-controlled mode. dyssynchrony may be seen as negative deflections ("m" waves) in the flow-time waveform, as shown in fig. 2 . in contrast the airway pressure may only be changed minimally by patient effort. it is important to exclude reversible mechanical causes that might lead to patient distress and ventilator dyssynchrony. endobronchial intubation, obstruction of a major bronchus or pneumothorax should be excluded. usually ventilator dyssynchrony can be managed by increasing sedation. however, in many cases it may be preferable to use intermittent muscle relaxants to fully control ventilation. it also may be helpful to trial the patient on assisted spontaneous breathing (asb) to improve ventilation synchrony, if peep is ≤ 10 cmh 2 o and the fio 2 is ≤ 40%. however, caution should be exercised, lest the patient become exhausted (see "weaning"). these guidelines are a pragmatic and consistent way to transition patients to asb. weaning is challenging and difficult to protocolise because there are many different factors to consider. for this reason, the weaning process is typically determined by clinical judgement. however, the guidelines presented here are set to ensure consistency of care. asb is considered when the participant's condition is improving. they should preferably be afebrile, have resolution of the underlying processes that led to their icu admission and improving gas exchange. they should have improving muscle strength, decreasing sedation requirements with an improving glasgow coma score (gcs) and richmond agitation sedation score (rass) between −3 and +1. generally, the fio 2 should be ≤ 40% and peep ≤ 10 cmh 2 o. if the following are substantially present, then participants may be transitioned to asb: 1. improving condition 2. minute ventilation acceptable (ve) ≤ 0.2 l/kg 3. fio 2 ≤ 40% 4. spo 2 93-95% 5. ph ≥ 7.3 6. heart rate ≤ 120 beats/min 7. low vasoactive drug requirements (noradrenaline + adrenaline ≤ 10 mcg/min) the following instructions or recommendations are used to guide transition to asb: the following observations should be made: oxygenation, re-sedate and revert back to the previous controlled ventilation mode (bi-level or pc-simv+ or equivalent); e. if the oxygenation has not improved after 12 h on controlled ventilation, or there is an unanticipated new problem causing deterioration, the participant should return to their previously assigned ventilation arm (mbv or spv), e.g.: iv. new lung injury/de-recruitment/aspiration/ sepsis. v. haemodynamic instability. vi. need to return to the operating room or to undergo invasive procedure. 2. if there is continual improvement, proceed towards separation from mechanical ventilation (extubation or continuous positive airway pressure (cpap) via a tracheostomy). a simplified flow chart of the patient enrolment process can be found in additional file 1. all study data, including ventilation data, patient and family/friend consent, sae reports and other documentation will be stored in a repository. consolidated standards of reporting trials (consort) figure 3 shows the consort diagram for the cure rct. patients recruited into the cure rct will have the following data collected. patient demographic and history the following data will be collected: 1. patient gender, height, weight and ethnicity 2. primary patient diagnosis contributing to ards or impaired lung function 3. secondary patient diagnosis contributing to ards or impaired lung function 4. relevant past medical history, e.g. smoking, medication, cardiovascular disease 5. chest x-ray score derived by the murray index [35] patient mechanical ventilation data data on patient airway pressure and flow generated from the mechanical ventilator will be recorded using the cure software (cure soft.) provided with the rct. the patient data are backed up regularly to external storage with encryption applied using veracrypt encryption software [36] . the following information will be collected: or ventilation-free days 9. amount of sedation -to account for possible data variation resulting from use of different sedatives 10. duration of icu stay 11. frequency and duration of renal support therapies 12. all causes of icu, hospital and 90-day mortality no person or authority will have access to the participant's blood. the blood samples are not stored. they are discarded and incinerated as soon as practicable, in accordance with nzs 4304:2002 "healthcare waste management". all cure rct data will be stored at the university of canterbury (uc). all paper forms (patient sheets, consent forms, etc.) will be scanned and stored at the uc. all electronic data will be stored in double-encrypted repository and only the participating researchers have access to it. currently there are no plans for sharing the data, but if requested, data may be shared. participants in the study can request their copy of data. the data will be backed up weekly and again, once the participant has finished the trial and left the hospital. this task will only be performed by the participating researchers. any protocol variations will be followed up and noted. the cure rct will store data for 20 years. the trial will utilise a primary composite end point incorporating the auc of the p/f ratio over the period of mv. every participant in the intervention (mbv) group is compared with every participant in the control (spv) group. test statistics will be calculated using the onesided wilcoxon rank sum test at alpha of 0.05. if results show no statistically significant difference between the intervention and control, it will result in the rejection of the intervention treatment as a standard of care and thus, the secondary clinical outcome assessments will include the number of desaturation events measured as peripheral capillary oxygen saturation < 90%, lomv, vfd for 28 days, the quality of mechanical ventilation care measured as the auc of spo 2 /fio 2 and chest x-ray index scores over time. the test statistic will be calculated using the one-sided wilcoxon rank sum test at alpha of 0.05. a difference in the primary outcome will show the impact of mbv compared to spv. no difference would show that enhanced, model-based metrics of the patient-specific condition have no effect on patient-centred or clinical outcomes. either outcome will yield clinical guidance. a monte-carlo simulation was performed to determine the sample size and determined that a minimum effective sample size of approximately 160 patients per arm is required to identify a 25% reduction in median lomv, with 0.8 power, at a double-sided significance level of 5% [37] . a linear alpha spending approach will be used for early termination of the trial for safety. linear alpha spending falls between a pocok and o'brien-fleming boundary [38] . with analysis points of 50, 75, 100, 125 and 160 patients per arm, and assumed control group mortality of 0.2, the mortality difference required to stop the trial (mortality intervention -mortality control ) at each analysis point respectively is 0.20, 0.16, 0.14, 0.12 and 0.10. this approach has cumulative α = 0.025. ethics approval has been filed with the new zealand national health and disability ethics committee. the cure rct clinical protocol and data usage has been filed with the new zealand south regional ethics committee (reference number 14/sth/132). the cure trial is also registered in the australian new zealand clinical trial registry (actrn12614001069640). all results and any subsequent analysis will be published and only the participating investigators will be authors. currently there is no plan to share data with other organisations. the data collected in this study will also be used for future research. adverse event (ae) and sae reporting (aes are defined as any unexpected change in physiology in a study participant associated with either the rm max or pump. this does not necessarily have to have a causal relationship with the aforementioned procedures. typically, this would be an unexpected, non-life-threatening event, which rapidly resolves following simple corrective measures. for example, hypotension will occur in most participants undergoing an rmmax or pump. however, if the procedure had to be shortened or abandoned, but the participant recovered with simple corrective measures (e.g. temporarily increasing noradrenaline by ≥ 5 mcg/min) or giving > 500 ml fluid bolus) this would be recorded as an ae. it is very important these events are accurately recorded as risk factors for aes that need to be defined when carrying out rms (as seen in additional file 3). saes are defined as any untoward medical occurrence that (1) results in death; (2) is life-threatening; (3) prolongs hospitalisation or (4) results in disability or incapability. however, baseline mortality in the patients in intensive care who are enrolled in the trial will likely be high due to the critical illness necessitating admission to the icu. despite attempts at prevention, trial participants will frequently develop lifethreatening organ failure(s) unrelated to study interventions. events that are a part of the natural history of the primary disease process or expected complications of critical illness will not be reported as saes in this trial. additionally, events already defined and reported as study outcomes, such as mortality or readmission to the icu, will not be labelled and reported separately as saes unless they are considered to be causally related to the study intervention or are otherwise of concern in the investigator's judgement. saes will be reported to the principal investigator within 24 h of any investigator becoming aware of the event. the minimum information to report includes: the nature of the event the time the event commenced and ceased an investigator's opinion of the relationship between study involvement and the event (not related, unlikely, possibly, probably or definitely related) whether treatment was required for the event and what treatment was administered saes could include pneumothorax, hypotension leading to cardiac arrest, transient desaturation leading to severe or prolonged desaturation, tachycardia, bradycardia, arrhythmia, anaphylaxis and unintended protocol deviations. in the unlikely event of a physical injury to the participant as a result of their participation in this study, they will be eligible to apply for compensation from the accident compensation corporation (acc) nz within its limitations. if the participant's family/friend have any questions about the acc, they will be able to ask the researchers for more information before they agree to take part in this trial. acc cover is not automatic and their case will need to be assessed by the acc according to the provisions of the 2001 injury prevention rehabilitation and compensation act. if the claim is accepted by the acc, the patient still might not receive compensation. this depends on a number of factors such as whether they are earners or non-earners. the acc usually provides only partial reimbursement of costs and expenses and there may be no lump sum compensation payable. there is no cover for mental injury unless it is a result of physical injury. if your relative or friend has acc cover, generally this will affect their right to sue the investigators. an independent dmc comprising experts in clinical trials, biostatistics and intensive care medicine is established before patient enrolment, to review all trial protocols and oversee and advise on this trial. the dmc will be forwarded a copy of all sae reports as soon as they become available to the trial investigators. the dmc will review all sae reports that they receive and report back to investigators if any further action is required. the steering committee of the cure rct comprises the primary investigators geoff shaw, geoff chase, chris pretty and yeong shiong chiew. the clinical data are collected by research nurses in the icu and mechanical ventilation data and oxygenation (bedside monitor) data will be collected by researchers from the uc. all study data will be stored in the double-encrypted repository at uc. data will be interpreted by participating researchers. the open and closed case interim reports will be compiled by paul docherty every 6 months and when 50 and 100 patients have been included. the dmc will have authority to continue or stop of the trial based on the interim reports. mechanical ventilation using peep set at minimum elastance has long been investigated in both experimental and clinical trials. these studies ranged from healthy patients under general anaesthesia to those with ards. however, only a few studies have investigated the clinical potential of peep set at minimum elastance. recent studies by pintado et al. [22] and chiew et al. [23] have shown the potential and feasibility of ventilating patients using minimum elastance peep. however, setting peep based on elastance is problematic due to the increased need of muscle relaxants, protocol burden and potential contradictory findings [22, 23] . the pilot trial was also underpowered and thus, a larger clinical trial such as the cure rct is required to provide further insight and validate the potential benefit of optimising mechanical ventilation peep with model-based methods. the cure rct implements a protocolised staircase peep recruitment manoeuvre together with novel computer software to calculate respiratory system elastance in real time. the computer software, cure soft [25] , uses a single compartment lung model [39] together with other model-based approach [24, 40] to aid clinicians during peep selection. this process potentially reduces selected peep variability and provides more consistent clinical guidance. there are several limitations of the cure rct design that should be noted. in particular, the rm is a doublestaircase manoeuvre and is design specific. studies have shown that not all patients benefit from rms [41, 42] , and the benefit of an rm is dependent on the patientspecific disease state, as well as the design of the rm. the double-staircase rm in this trial was designed to assess lung recruitment and provide consistent peep titration. it is noted that not all patients included in this study will necessarily demonstrate alveolar lung recruitment. another limitation worth noting is the control group clinical protocol. clinically, there is relatively little consensus an optimal mechanical ventilation mode. thus, the standard practice ventilation in the participating hospital relies on general approaches [2] and is highly variable between clinicians. there may be no equal comparator for a mechanical ventilation study resulting from this variability. patients recruited to the cure rct will have the mv mode set to bi-level ventilation in both the intervention and the control group; it is debatable that bi-level ventilation may lack certain ventilation advantages. however, this procedure will reduce variability and provides the opportunity for fair comparison between groups. in the participating icu, there are > 700 patients per year requiring invasive mv; however, only an average of < 5 patients were diagnosed with ards as the primary diagnosis per year. ards is nearly always regarded as a complication of an acute process. one concern is that the desired sample size cannot be achieved. however, this number is also too small compared to reports [43, 44] . the small number may be due to changes in the ards definition [27, 45] and misdiagnosis [46] . estenssoro et al. [46] report that misdiagnosis could occur due to delayed screening. thus, in the cure rct, any patient requiring invasive mechanical ventilation is screened immediately, as per villar et al. [27] , whereby the p/f ratio is measured at peep = 5 cmh 2 o, and fio 2 = 50%. equally, retrospective screening was also performed and identified > 200 patients eligible for the trial per year. hence, a 3-year study is planned to achieve the target sample size at an estimated recruitment rate of 50%. optimising patient-specific mechanical ventilator settings remains a huge clinical challenge due to patient disease variability, as well as clinical practice variability. thus, there is a need for a method to provide consistent patient-specific treatment. the cure rct is the first single-centre large clinical rct using model-based minimum elastance peep selection in mechanical ventilation. it provides a means to select patient-specific peep in a consistent fashion and patient outcomes are compared to current practice. the cure rct investigation group hope that the results from this trial will support the use of model-based methods to estimate optimal peep, and will serve as a platform to assess other patient-centred outcomes in future mechanical ventilation studies in ards/ali. analysis. td, bb, as and km provided advice on the study protocol. all authors read and approved the final manuscript. this research is funded by the new zealand health research council (hrc) (hrc reference 13/213) under project pulmods: pulmonary model-based decision support to optimise ards/ali care. hrc does not have any role in this study and future analysis. they were not part of study design and will not be part of any management or analysis of the trial. currently there are no plans to share any of the data. the cure rct clinical protocol and data usage has been granted by the new zealand south regional ethics committee (reference number 14/sth/ 132). the cure rct is registered in the australian new zealand clinical trial registry (actrn12614001069640). the trial was registered on 22 september 2014 (https://www.anzctr.org.au/trial/registration/trialreview.aspx?id=36683 8&isreview=true). the cure rct will recruit patients once family consent is obtained. however, if the treating clinician firmly believes a recruitment manoeuvre is in the best interests of the patient, and no family is available for consent, the participant will be enrolled and randomised and the appropriate protocolised recruitment manoeuvre will follow. in this case, delayed consent is obtained as early as possible. once the participant recovers from their condition and is discharged from the icu, we will seek their informed consent. not applicable. mechanical ventilation in ards: a state-of-the-art review ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome a high positive end-expiratory pressure, low tidal volume ventilatory strategy improves outcome in persistent acute respiratory distress syndrome: a randomized, controlled trial ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial positive end-expiratory pressure setting in adults with acute lung injury high levels of peep may improve survival in acute respiratory distress syndrome: a meta-analysis higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome low mortality associated with low volume pressure limited ventilation with permissive hypercapnia in severe adult respiratory distress syndrome positive end-expiratory pressure the preventive role of higher peep in treating severely hypoxemic ards combined effects of ventilation mode and positive end-expiratory pressure on mechanics, gas exchange and the epithelium in mice with acute lung injury reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome how large is the lung recruitability in early acute respiratory distress syndrome: a prospective case series of patients monitored by computed tomography computed tomography assessment of positive end-expiratory pressure-induced alveolar recruitment in patients with acute respiratory distress syndrome ventilation and weaning practices in australia and new zealand positive end-expiratory pressure at minimal respiratory elastance represents the best compromise between mechanical stress and lung aeration in oleic acid induced lung injury use of dynamic compliance for open lung positive end-expiratory pressure titration in an experimental study comparison of functional residual capacity and static compliance of the respiratory system during a positive end-expiratory pressure (peep) ramp procedure in an experimental model of acute respiratory distress syndrome optimum end-expiratory airway pressure in patients with acute pulmonary failure individualized peep setting in subjects with ards: a randomized controlled pilot study feasibility of titrating peep to minimum elastance for mechanically ventilated patients model-based peep optimisation in mechanical ventilation the clinical utilisation of respiratory elastance software (cure soft): a bedside software for real-time respiratory mechanics monitoring and mechanical ventilation management the ards definition task force, definition tb a universal definition of ards: the pao2/fio2 ratio under a standard ventilatory setting-a prospective, multicenter validation study driving pressure and survival in the acute respiratory distress syndrome mechanical ventilation to minimize progression of lung injury in acute respiratory failure ventilation-induced lung injury exists in spontaneously breathing patients with acute respiratory failure: yes a minimal algorithm for a minimal recruitment model-model estimation of alveoli opening pressure of an acute respiratory distress syndrome (ards) lung patient-ventilator asynchrony during assisted mechanical ventilation patient-ventilator asynchronies: may the respiratory mechanics play a role? observational study of patientventilator asynchrony and relationship to sedation level ☆ an expanded definition of the adult respiratory distress syndrome effective sample size estimation for a mechanical ventilation trial through monte-carlo simulation: length of mechanical ventilation and ventilator free days designs for group sequential tests lung mechanics at the bedside: make it simple time-varying respiratory system elastance: a physiological model for patients who are spontaneously breathing recruitment maneuvers for acute lung injury new and conventional strategies for lung recruitment in acute respiratory distress syndrome the australian and new zealand intensive care society clinical trials group. incidence and mortality of acute lung injury and the acute respiratory distress syndrome in three australian states incidence and outcomes of acute lung injury report of the american-european consensus conference on ards: definitions, mechanisms, relevant outcomes and clinical trial coordination impact of positive end-expiratory pressure on the definition of acute respiratory distress syndrome publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors wish to thank the christchurch hospital intensive care medical, nursing and technical staff for the support of this clinical trial. the authors declare that they have no competing interests. the trial has not started recruiting yet. the trial is estimated to start in december 2019 in christchurch hospital intensive care unit. the trial is estimated to be completed by may 2022. this is protocol version number 2.0, dated 20 august 2019. supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-019-4035-7.additional file 1. screening process diagram. key: cord-286237-x6dr6rsh authors: maes, bastiaan; bosteels, cedric; de leeuw, elisabeth; declercq, jozefien; van damme, karel; delporte, anja; demeyere, bénédicte; vermeersch, stéfanie; vuylsteke, marnik; willaert, joren; bollé, laura; vanbiervliet, yuri; decuypere, jana; libeer, frederick; vandecasteele, stefaan; peene, isabelle; lambrecht, bart title: treatment of severely ill covid-19 patients with anti-interleukin drugs (cov-aid): a structured summary of a study protocol for a randomised controlled trial date: 2020-06-03 journal: trials doi: 10.1186/s13063-020-04453-5 sha: doc_id: 286237 cord_uid: x6dr6rsh objectives: the purpose of this study is to test the safety and effectiveness of individually or simultaneously blocking il-6, il-6 receptor and il-1 versus standard of care on blood oxygenation and systemic cytokine release syndrome in patients with covid-19 coronavirus infection and acute hypoxic respiratory failure and systemic cytokine release syndrome. trial design: a phase 3 prospective, multi-center, interventional, open label, 6-arm 2x2 factorial design study. participants: subjects will be recruited at the specialized covid-19 wards and/or icus at 16 belgian participating hospitals. only adult (≥18y old) patients will be recruited with recent (≤16 days) covid-19 infection and acute hypoxia (defined as pao2/fio2 below 350mmhg or pao2/fio2 below 280 on supplemental oxygen and immediately requiring high flow oxygen device or mechanical ventilation) and signs of systemic cytokine release syndrome characterized by high serum ferritin, or high d-dimers, or high ldh or deep lymphopenia or a combination of those, who have not been on mechanical ventilation for more than 24 hours before randomisation. patients should have had a chest x-ray and/or ct scan showing bilateral infiltrates within the last 2 days before randomisation. patients with active bacterial or fungal infection will be excluded. intervention and comparator: patients will be randomized to 1 of 5 experimental arms versus usual care. the experimental arms consist of anakinra alone (anti-il-1 binding the il-1 receptor), siltuximab alone (anti-il-6 chimeric antibody), a combination of siltuximab and anakinra, tocilizumab alone (humanised anti-il-6 receptor antibody) or a combination of anakinra with tocilizumab in addition to standard care. patients treated with anakinra will receive a daily subcutaneous injection of 100mg for a maximum of 28 days or until hospital discharge, whichever comes first. siltuximab (11mg/kg) or tocilizumab (8mg/kg, with a maximum dose of 800mg) are administered as a single intravenous injection immediately after randomization. main outcomes: the primary end point is the time to clinical improvement defined as the time from randomization to either an improvement of two points on a six-category ordinal scale measured daily till day 28 or discharge from the hospital or death. this ordinal scale is composed of (1) death; (2) hospitalized, on invasive mechanical ventilation or ecmo; (3) hospitalized, on non-invasive ventilation or high flow oxygen devices; (4) hospitalized, requiring supplemental oxygen; (5) hospitalized, not requiring supplemental oxygen; (6) not hospitalized. randomisation: patients will be randomized using an interactive web response system (redcap). a 2x2 factorial design was selected with a 2:1 randomization regarding the il-1 blockade (anakinra) and a 1:2 randomization regarding the il-6 blockade (siltuximab and tocilizumab). blinding (masking): in this open-label trial neither participants, caregivers, nor those assessing the outcomes are blinded to group assignment. numbers to be randomised (sample size): a total of 342 participants will be enrolled: 76 patients will receive usual care, 76 patients will receive siltuximab alone, 76 patients will receive tocilizumab alone, 38 will receive anakinra alone, 38 patients will receive anakinra and siltuximab and 38 patients will receive anakinra and tocilizumab. trial status: cov-aid protocol version 3.0 (15 apr 2020). participant recruitment is ongoing and started on april 4(th) 2020. given the current decline of the covid-19 pandemic in belgium, it is difficult to anticipate the rate of participant recruitment. trial registration: the trial was registered on clinical trials.gov on april 1st, 2020 (clinicaltrials.gov identifier: nct04330638) and on eudract on april 3rd 2020 (identifier: 2020-001500-41). full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. is characterized by series of overlapping networks. cytokines tnf and il-1α and the chemotactic cytokines il-8 and mcp-1 are indicative of an acute response that appear almost immediately after infection, followed by a more sustained increase in il-6. interactions between il-6 and its soluble receptor enhance the activity of il-6 on target cells to further aggravate inflammation. il-6 production is stimulated by tnf and il-1b, therefore a measurement of il-6 concentration in peripheral blood has often been used to assess the intensity of systemic cytokine responses in patients with sepsis, providing an integrated readout signal of these two early-response cytokine. compensatory repair processes are initiated soon after inflammation begins, in an attempt to restore tissue and organ function. il-10, which is an anti-inflammatory cytokine is secreted as the body attempts to control the acute systemic inflammatory response. systemic production of il-10 following the onset of a cytokine storm can serve as a marker of counter-anti-inflammatory response that has been termed "immunoparalysis", in that it is associated with downregulation of neutrophil and monocyte function in the systemic circulation, and leads to downregulation of hla-dr on monocytes. the same cytokines that cause the systemic response and are leading to rise in ferritin and crp as biomarkers, are also profoundly involved in causing acute lung injury. acute lung injury is accompanied by epithelial cell damage (loss of type 1 pneumocytes that line the alveolar space), initiation of the coagulation cascade (with endothelial and interstitial fibrin deposition) and activation of the complement cascade, which leads to further cell recruitment and perpetuation of damage. a balance of pro-and anti-inflammatory mechanisms is critical for maintaining the immune homeostasis systemically and in the lung and if one or more of these regulatory mechanisms are absent or aberrantly regulated, then the outcome may contribute toward a cytokine storm and progression of acute lung injury to franc clinical ards. downregulation of systemic inflammation might be conceptually beneficial in controlling systemic responses to local infections. however, it has been suggested that patients who survive the initial cytokine storm but subsequently die, may be those who do not recover from immunoparalysis. patients with persistent downregulation of hla-dr (a marker of immunosuppression) on monocytes 3 to 4 days after the onset of severe sepsis and cytokine storm have a high mortality rate, suggesting a rationale for therapy to reverse immunosuppression under such circumstances. 13/45 the proposed development plan was guided by three specific considerations: 1. supportive scientific rationale: predictors of fatality from a recent retrospective, multicentre study of 150 confirmed covid-19 cases in wuhan, china, included elevated ferritin (mean 1297·6 ng/ml in non-survivors vs 614·0 ng/ml in survivors; p<0·001) and il-6 (p<0·0001), suggesting that mortality might be due to virally driven hyperinflammation (1, 2). respiratory failure from (ards) is the leading cause of mortality in covid-19 (4, 5) . a cytokine profile resembling shlh is associated with covid-19 disease severity, characterised by increased interleukin (il)-2, il-7, granulocyte-colony stimulating factor, interferon-γ inducible protein 10, monocyte chemoattractant protein 1, macrophage inflammatory protein 1-α, and tumour necrosis factor-α (2). liu concluded by analyzing 69 severe type covid -19 patients that on admission, the baseline levels of il-6, crp, ldh and ferritin were closely related to the severity of covid-19, and the elevated il-6 was significantly related to the clinical manifestation of severe type patients. the decrease of il-6 was linked to treatment effectiveness, while the increase of il-6 indicated disease exacerbation. there was mild variation in il-2, il-4, il-10, tnf-a, ifn-γ before and after treatment, all of which fluctuated within the normal range. in another cross-sectional study, 100 patients were included and divided into mild, severe or critical groups. correlation of peripheral blood inflammation-related indicators with disease was criticality analyzed. cut-off values for critically ill patients were speculated using roc curve analyses. with following parameters such as age (r=-0.564, p67.5 years, il2r >793.5u/ml, crp >30.7ng/ml, ferroprotein >2252μg/l, wbc>9.5*10^9/l or nc >7.305*10^9/l, the progress of covid-19 to critical stage should be closely observed and possibly prevented. they eventually state that as inflammation is closely related to severity of covid-19, il-6, tnfα and il-8 might be promising therapeutic targets. similar analysis on cytokines and cells has been done on another group of 102 mild and 21 severe covid-19 patients. significant differences were noticed between the two groups in cd4 + t, cd8 + t, il-6 and il-10 with low levels of cd4+t and cd8+t and higher il-6 and il-10 levels in severe patients (12) interleukin 1 is known as an inducer of fever and induces crp, which is often enhanced in patients with severe covid-19. il-1 is an important mediator of fever in autoinflammatory syndromes/inflammasomopathies such as nomid, caps, and still's disease. interleukin-1 is also an important mediator in acute lung injury. although less evidence supports high levels of il-1 in covid-19 patients, this could be due to the fact that il-1 is hard to measure in the serum of these patients, and could better be addressed by measuring levels of il-1ra. il-1 blockade using anakinra is currently also suggested as an arm in the multicentre remapcap trial in icu patients, built in as a new arm addition to the existing trial, because of the emerging covid-19 crisis. re-analysis of data from a phase 3 randomized controlled trial of il-1 blockade (anakinra) in sepsis with ards showed significant survival benefit in patients with hyperinflammation, without increased adverse events (3) . preliminary data reported on 21 patients in an open label study report a favourable clinical evolution of tocilizumab treated patients, with reduction in fever, hyperferritinemia, cytopenia. a multicentre, randomised controlled trial of tocilizumab (il-6 receptor blockade, licensed for cytokine release syndrome), has been approved in patients with covid-19 pneumonia and elevated il-6 in china (chictr2000029765). this 63 patient study has been completed, but formal analysis has not been published. a large 400 patient adaptive phase 2/3, randomized, double-blind, placebocontrolled study assessing efficacy and safety of sarilumab (anti-il6r) for hospitalized patients with covid-19 versus best standard of care has been launched in stage2b patients with covid-19 infection in the us by sanofi/regeneron. (clinicaltrials.gov identifier: nct04315298). primary endpoints in that study will be clinical evolution on a six score scale, and time to resolution of fever >48h. important secondary endpoints include parameters of lung oxygenation (pao2/fio2), and clinical outcome (hospital stay, all-cause mortality at 28 days). the fda has also approved the initiation of a doubleblind, randomized phase iii clinical trial (covacta) of tocilizumab for use in combination with standard of care. the trial is about to start. preliminary data obtained at hospital st.-pierre brussels show that il-6 levels are increased in a subset of covid-19 stage-3 patients, and that tocilizumab (tcz) reduces key inflammatory parameters like crp, while improving oxygenation. 3. expediency: toxicology, pharmacologic and safety data supports the immediate clinical use of il-6 and/or il-1 blockade in severe hypoxia and ards and in features of shlh due to covid-19 (5, 6) . investigator brochures of these drugs are available and contain detailed information on toxicity. risk/benefit assessment covid-19 poses a very significant risk of mortality of 3-7% and this percentage rises to mortality of 20% in patients with co-morbidity (2, 7) . of all infected patients, some 15-20% develop acute lung 15/45 injury and severe respiratory symptoms necessitating hospital admission. around 5% of infected patients will require invasive mechanical ventilation, and many of those (40-50%) will die. the current world-wide pandemic of covid-19 is putting unforeseen stress on the entire primary, secondary and tertiary medical system, leading to unseen triage of patients that potentially benefit or not from admission to icu units when they develop respiratory failure . there are currently no treatments directed at improving gas exchange, cytokine release syndrome, and shlh in covid-19 patients, and no treatment that attempts to halt the progression from manageable acute hypoxic respiratory failure to ards (5, (8) (9) (10) (11) . preventing such progression to ards could have a huge impact on the foreseeable overflow of the icu units. we therefore believe the benefits of administering anti-il6r and/or il-1 blockade treatment in early stage covid-19 acute hypoxic respiratory failure and signs of cytokine release syndrome outweighs the risks associated with a phase 4 imp administration. anakinra was first approved for use in ra in the us in 2001 and subsequently in the eu in 2002. more than 3000 patients were involved in this development program. the initial ind for anakinra was granted in 1991. the estimated cumulative exposure to anakinra in completed company sponsored clinical studies up to may 1 st 2018 is 6404 subject years in 8518 subjects with various indications. since approval in 2001 the total post marketing exposure of anakinra is > 102.000 patient years. anakinra is administered s.c. at doses of 100 mg/day (ra) or in weight based dosing up to 8mg/kg/day in nomid syndrome. in sepsis, several trials have used doses up to 2 mg/kg/hour iv over 72 hours to more than 500 patients, and were well tolerated. re-analysis of data from a phase 3 randomized controlled trial of il-1 blockade (anakinra) in sepsis showed significant survival benefit in patients with hyperinflammation, without increased adverse events(3). there is a large number of covid-19 infected patients that are currently being hospitalized across the globe. by 30 march 2020, over 4524 patients have been admitted to belgian hospitals with severe respiratory symptoms, and 513 people have died and 927 are admitted to the icu, most likely all with severe acute lung injury. worldwide, more than 31680 people have died as of march 29. we therefore believe that given the current ascending part of the epidemiology curve, with numbers of patients rising sharply, there will be no shortage of patients that are eligible. there is currently a lot of pressure on using the imps as off-label indications to treat covid-19 worldwide. we have checked availability of these drugs for investigational use with belgian representatives of the company and have confirmation from roche, eusapharma and sobi that sufficient drug will be reserved for purchase as trial medication for this trial. a recent who ad hoc informal consultation on the use of il-6/il-1 antagonists in the clinical management of covid19 infection convened on march 25 th 2020 in geneva and concluded that if we are to understand the real value of these immunomodulatory therapies and understand their risks and benefits, the limited stock of drugs should best be used to perform randomized controlled trials. 16/45 justification for our objective is that preventing cytokine release syndrome and progression from early hypoxic respiratory failure and mild acute lung injury to ards could have a huge impact on the foreseeable overflow of the icu units. the outcome of our study could thus have large impact from a medical, ethical and economic perspective. the hypothesis of the proposed intervention is that il-6 and/or il-1 are important mediators of the cytokine release syndrome that has an important impact on acute lung injury and development of secondary cytopenias post covid-19, and thus affect clinical outcome of the patients the primary objective of this intervention is : study if blockade of il-6 +/-il-1 to block the cytokine storm and acute lung injury in comparison with usual care reduces time to clinical improvement as defined by an increase of more than 2 on the 6 point ordinal scale or discharge from the hospital 2.5. secondary objectives -to investigate whether treatment with either tocilizumab, siltuximab, anakinra or combinations thereof -improves oxygenation -causes defervescence, measured as time to first fever-free 48h period -improves features of secondary haemophagocytic lymphohistiocytosis -improves features of secondary haemophagocytic lymphohistiocytosis in relation to serum il-6 and il-1 -affects clinical outcome in relation to il-6 and il-1 levels -affects the rate of nosocomial infection -affects progression to mechanical ventilation, high oxygen delivery device, and/or ards in non-ventilated patients -affects length of dependency of ventilation in ventilated patients -affects all-cause mortality rate at 4 and 20 weeks post inclusion -affects long term 10-20 week follow up clinical status and lung function -is safe (number of aes/saes/sars/susars) -when there is a significant association between il-6 blockade and time to clinical improvement, tocilizumab and siltuximab will be compared versus usual care separately with respect to the primary endpoint. this is a multi-center, interventional, open label, 6-arm 2x2 factorial design study designed to investigate the efficacy of tocilizumab, tocilizumab and anakinra, siltuximab, siltuximab and anakinra and anakinra alone versus usual care in improving short-and long-term outcome of covid-19 patients with hypoxia and signs of cytokine release syndrome. a 2x2 factorial design was selected because it allows to answer two research questions simultaneously, while minimizing the number of patients enrolled in the trial, which is important in view of the emerging shortage of interleukinblocking therapies. in addition, the number of patients not receiving study medication is kept to a minimum, which is more justifiable in such a severe disorder as covid-19. there are currently no treatments directed at halting the cytokine storm and acute lung injury to stop the progression from manageable hypoxia to frank respiratory failure and ards (5, 9) . preventing progression from early acute hypoxia and cytokine release syndrome to frank hypoxic respiratory failure and ards could have a huge impact on the foreseeable overflow of the icu units, that is already happening in some countries and is bound to happen on a global scale. in ventilated patients, preventing the onset of ards, or shortening icu stay could also be crucial in this regard. the study will be performed in adults, because several of the patients will have to be admitted to the intensive care unit. in pediatric patients, the presence of cytokine has been less described, and paediatric icu units currently have limited experience and numbers of covid-19 patients with cytokine release syndrome. ` to measure the effectiveness of tocilizumab, tocilizumab and anakinra, siltuximab, siltuximab and anakinra and anakinra versus usual care on restoring lung homeostasis, we will assess the time to clinical improvement as defined as the time from randomization to either an improvement of two points on a six-category ordinal scale or discharge from the hospital using single iv injection (siltuximab or tocilizumab) combined or not with daily subcutaneous injections of anakinra until 28 days or hospital discharge, whichever is first. during the treatment period, we will perform daily clinical assessments of severity, daily laboratory check-up, measurements of oxygen saturation (pulse oximetry) in relation to fio2, regular arterial blood gas measurements, regular chest x-rays, chest ct scans on clinical indication. the subject has completed the study if he or she has completed all phases of the study, including the last visit (week 10-20 clinical follow up visit) or the last scheduled procedures, as described in this protocol (see section "8. study specific procedures"). for the primary endpoint, the last patient will be followed until the event has been observed or until 28 days after randomisation, whichever comes first. overall, the end of the study is reached when the last study procedure for the last subject has occurred: last subject, last visit (lslv). as soon as the whole study has ended (cfr. the definition above), the co-ordinating investigator shall notify the hiruz clinical trial unit, so that the competent authority and the ethics committee can be informed in a timely manner according to the regulatory requirements (within 90 days after end of the study, or if the study had to be terminated early, this period must be reduced to 15 days and the reasons should clearly explained). there is a large number of covid-19 infected patients that are currently being hospitalized across the globe. in just 15 days time, the covid-19 ward at ghent university hospital has admitted 85 confirmed cases, of which a significant portion (30%) already fulfilled eligibility criteria for the current proposed protocol. we estimate the study to terminate in 32 weeks, including last clinical follow up visits. the following patients will be enrolled -recent (≥6 days of flu-like symptoms or malaise yet ≤16 days of flu-like symptoms or malaise prior to randomization) infection with covid-19.confident covid-19 diagnosis confirmed by antigen detection test and/or pcr and/or positive serology, or any emerging and validated diagnostic laboratory test for covid-19 within this period. -in some patients, it may be impossible to get a confident laboratory confirmation of covid-19 diagnosis after 24h of hospital admission because viral load is low and/or problems with diagnostic sensitivity. in those cases, in absence of an alternative diagnosis, and with highly suspect bilateral ground glass opacities on recent (<24h) chest-ct scan (confirmed by a radiologist and pulmonary physician as probable covid-19), and a typical clinical and chemical diagnosis with signs of cytokine release syndrome, a patient can be enrolled as probable covid-19 infected. in all cases, this needs confirmation by later seroconversion. -presence of hypoxia defined as pao2/fio2 below 350 while breathing room air in upright position or pao2/fio2 below 280 on supplemental oxygen and immediately requiring high flow oxygen device or mechanical ventilation. -signs of cytokine release syndrome defined as any of the following -serum ferritin concentration >1000 mcg/l and rising since last 24h -single ferritin above 2000 mcg/l in patients requiring immediate high flow oxygen device or mechanical ventilation -lymphopenia defined as <800 lymphocytes/microliter and two of the following extra criteria ferritin > 700 mcg/l and rising since last 24h -increased ldh (above 300 iu/l) and rising since last 24h -d-dimers > 1000 ng/ml and rising since last 24h -crp above 70 mg/l and rising since last 24h and absence of bacterial infection -if three of the above are present at admission, no need to document 24h rise -chest x-ray and/or ct scan showing bilateral infiltrates within last 2 days -admitted to specialized covid-19 ward or an icu ward taking care of covid-19 patients -age ≥ 18 years -male or female -women of childbearing potential must have a negative serum pregnancy test pre-dose on day 1. women of childbearing potential must consistently and correctly use (during the entire treatment period and 3 months after last reatment) 1 highly effective method for contraception. -willing and able to provide informed consent or legal representative willing to provide informed consent -patients with known history of serious allergic reactions, including anaphylaxis, to any of the study medications, or any component of the product. -mechanical ventilation > 24 h at randomization -clinical frailty scale above 3 -active bacterial or fungal infection -unlikely to survive beyond 48h -neutrophil count below 1500 cells/microliter -platelets below 50.000/microliter -patients enrolled in another investigational drug study -patients on high dose systemic steroids (> 8 mg methylprednisolone or equivalent for more than 1 month) for covid-19 unrelated disorder -patients on immunosuppressant or immunomodulatory drugs -patients on current anti-il1 or anti-il6 treatment -signs of active tuberculosis -serum transaminase levels >5 times upper limit of normal, unless there are clear signs of cytokine release syndrome defined by ldh >300 iu/l and ferritin >700 ng/ml -history of (non-iatrogenic) bowel perforation or diverticulitis -pregnant or breastfeeding females (all female subjects deemed of childbearing potential by the investigator must have negative pregnancy test at screening) 5.2.1. screen failures screen failures are defined as subjects who consent to participate in the clinical study but are not subsequently randomly assigned to the study intervention or entered in the study. a minimal set of screen failure information will be kept to ensure transparent reporting of screen failure subjects. there is a large number of covid-19 infected patients that are currently being hospitalized across the globe. in just 14 days time, our covid-19 ward at ghent university hospital has admitted 91 confirmed cases, of which a significant portion (30%) already fulfil eligibility criteria for the current proposed protocol. similar numbers of patients are currently being seen in the participating centers in belgium. we therefore believe that given the current ascending part of the epidemiology curve, with numbers of patients rising sharply, there will be no shortage of patients that are eligible. 342 patients will be recruited within an accrual period of 8 weeks in order to observe 215 patients with clinical improvement (when the last patient has 28 days of follow-up). we expect to recruit 100 patients / week over all centers. subjects are free to withdraw from participation in the study at any time upon request. an investigator may discontinue further administration of study drug for the following reasons (however assessments will continue to be made and patients will remain in the intent to treat population for statistical analysis): • allergic reactions (anaphylactic shock) to study drugs • pregnancy • duration of mechanical ventilation has moved beyond >24h at time of randomization • significant study intervention non-compliance • if any clinical adverse event (ae), laboratory abnormality, or other medical condition or situation occurs such that continued participation in the study would not be in the best interest of the subject • if the subject meets an exclusion criterion (either newly developed or not previously recognized) that precludes further study participation the investigator can exceptionally discontinue further study procedures if they feel that the patient is too sick and that it wouldn't be ethical to continue treatment. however, all safety data must be collected. in all cases, the reason why subjects stopped study medication must be recorded in detail in the ecrf and in the subject's medical records. the following actions must be taken if a subject fails to return to the clinic for a required study visit (visit at 10-20 weeks post end of study) : • the site will attempt to contact the subject and reschedule the missed visit within 4 weeks and counsel the subject on the importance of maintaining the assigned visit schedule and ascertain if the subject wishes to and/or should continue in the study. • before a subject is deemed lost to follow-up, the investigator or designee will make every effort to regain contact with the subject (where possible, 3 telephone calls and, if necessary, a 24/45 certified letter to the subject's last known mailing address or local equivalent methods). these contact attempts should be documented in the subject's medical record or study file. • should the subject continue to be unreachable, he or she will be considered to have withdrawn from the study with a primary reason of lost to follow-up. subjects will be recruited at the covid-19 hospitalization ward and or icus at the participating centers. the study will be proposed by the treating physician to all subjects with confirmed covid-19 infection and a presence of hypoxia, and signs of cytokine release syndrome. there will be no compensation for study participation. study medication is paid for by kennis centrum kce, and dispatched from uz gent hospital pharmacy. since this is a hospital based trial, in which patients are severely ill and in infection quarantine, we suspect the retention in the trial to be high. patients will be informed about the study by the treating physician. after receiving full explanation, having received sufficient time to considerer the trial, asking questions and receiving satisfying responses to all questions, patients will be asked to sign icf. a serum pregnancy test will be done (female patients only). medical history will be checked for review of exclusion criteria and relevant subject information. patients will be continuously monitored on the covid-19 ward. exams (standard of care) include, but are not limited to: -ecg -chest x-ray, and/or ct-scan -laboratory tests for leukocyte formula, kidney and liver function, ferritin levels, ldh level -vital signs -pulse oximetry, arterial blood gas, capnography as soon as all in-and exclusion criteria are checked and patient is considered eligible, patient can be randomized in ivrs. this is allowed the day before d1 in order to make practical arrangements to start treatment. it has been used in treatment of metastatic kidney cell tumors, prostate cancer and multicentric form of castelman's disease. is an il-1 inhibitor binding to the il-1 receptor. it is indicated in eu for treatment of rheumatoid arthritis, cryopyrin-associated periodic syndromes (caps, nomid) and still's disease, a rare disease causing inflammation of joints as well as rash and fever. anakinra (kineret®) will be purchased and distributed from sobi tocilizumab (roactemra®) will be purchased and distributed from roche siltuximab (sylvant®) will be purchased and distributed from eusapharma drugs will be purchased by the central hospital pharmacy of uz gent and dispatched to other participating centers. shelf life : diluted product: after dilution the prepared infusion solution is chemically and physically stable in sodium chloride 9 mg/ml (0,9 %) injection solution at 30°c for a period of 24 hours. for safety reasons, the infusion solution should be used immediately to avoid growth of microbes. when injection cannot be done immediately, product quality and storage conditions are the responsibility of the person who prepared the solution, and the diluted product should not be stored longer than 24 hours at a temperature between 2-8°c. if product was diluted under controlled and validated aseptic conditions, storage time can be extended. shelf life closed injection vial: 30 months store injection vials refrigerated (2°c -8°c). do not freeze-thaw. keep injection vials away from direct sun light by storing them in the original packing. due to shortage of roactemra® for iv usage, some hospital will dispense roactemra® for subcutaneous route in infusion bags for iv injection, as per instructions of the manufacturer: for ambulatory use, kineret® may be removed from the refrigerator for a period of 12 hours at temperatures up to 25 ° c, without exceeding the expiration date. at the end of this period, the drug should not be put back in the refrigerator and should be destroyed. in this trial, we are targeting patients with covid-19 and signs of a beginning cytokine storm (reflected by increasing ferritin, crp, ldh and d-dimers and declining lymphocytes). in this phase of the disease, the levels of cytokines il-1 and il-6 are still in the range also found in patients with rheumatoid arthritis. therefore, the dosing of the imps is taken from the skp famhp, by analogy with indications in rheumatoid arthritis and castelman's disease. will be given via single iv infusion at a dose of 8 mg/kg with a maximum infusion of 800 mg/injection 8mg / kg (= 0.4ml / kg) in an infusion of 100ml nacl 0.9% and administration over 1 hour. if roactemra® is directly prepared from the vials for iv injection: no further specifications regarding the use of a 0.2 or 0.22 filter when administered. when the roactemra® iv infusion bag is prepared from prefilled syringes , use a po, pe, pp, pbd or pur infusion line with 0.2 or 0.22 µm pes or ps filter during administation. as a measure of precaution, an inline filter is mandatory. will be given via single iv infusion at a dose of 11 mg / kg given over 1 hour as an intravenous infusion in glucose 5% (ad-preparation: the same volume of product must be withdrawn from the infusion before adding the sylvant®) administer via using pvc, or polyurethane (pu), or pe coated administration sets with a 0.2-micron in-line polyethersulfone (pes) filter. will be given 1x / day 100 mg sc 28 days (or until discharge from hospital) do not shake. allow the pre-filled syringe to reach room temperature before the injection. subcutaneous injection; it is recommended that the injection site would be varied to avoid discomfort at the site of injection. cooling the injection site, prewarming/preheating the injection liquid to reach room temperature, use of cold packs (before and after the injection) and use of topical glucocorticoids and antihistamines after injection may reduce the signs and symptoms of the reaction at the injection site. no dose adjustments and interruptions are permitted during this trial. in case of anaphylaxis or severe ae, the drug will be immediately interrupted. since anaphylaxis to protein drugs like tocilizumab or siltuximab or anakinra is hard to predict and can occur already to very low doses in case of prior anaphylaxis, we will not attempt a subsequent dose reduction. anakinra (kineret®): the most common side effects (which may affect more than 1 patient in 10) are headache, injection site reactions (redness, bruising, pain and inflammation), and increase in blood cholesterol. for the full list of side effects of kineret®, see the package leaflet. kineret® must not be used in people who are hypersensitive (allergic) to anakinra, to any of the other ingredients, or to proteins produced by escherichia coli (a type of bacterium). kineret® must not be started in patients who have neutropenia. 29/45 there are no restrictions regarding concomitant/rescue medication. patients will be informed about the study by the treating physician. after receiving full explanation, having received sufficient time to considerer the trial, asking questions and receiving satisfying responses to all questions, patients will be asked to sign icf. the icf process will be performed before any other study related procedure. in this open label trial patients will be randomized using redcap (electronic ivrs system). we will use stratified permuted block randomization with varying block sizes. we will stratify according to center. the randomization will be done separately for the two main comparisons to reflect the factorial nature of the trial. for the comparison of anakinra versus usual care, the allocation ratio is 1:2 (more patients in the usual care group). for the comparison of il6 blockers (sylvant® and roactemra®) versus usual care, the allocation ratio is 1:2 (more patients on il6 blockers). within the group on il6 blockers, there is equal allocation to sylvant® and roactemra® (1:1). having two separate randomization schemes implies we cannot guarantee the perfect randomization ratios. however, it will allow for more flexibility in case not all centers have access to all drugs and it will reduce the maximum imbalance between two groups. this is a hospital based intervention trial, in which patients with covid-19 will be randomized to be treated with tocilizumab, tocilizumab and anakinra, siltuximab, siltuximab and anakinra, anakinra or usual care. patients with covid-19 infection and respiratory failure are severely ill, and will require multiple daily clinical exams, blood sampling (including blood procalcitonin levels), vital parameter measurements, blood oxygenation measurements, and chest x-rays. these are all part of the clinical management plan of the patients, and data stored in the electronic patient file will be used as part of the assessment of efficacy and safety profile of the study drugs. on screening, a blood sample will be taken, preferentially during routine blood sampling, to determine exclusion criteria (pregnancy, high ferritin level, ldh, d-dimers, blood lymphocyte counts, transaminases). on day 1, prior to tocilizumab, tocilizumab and anakinra, siltuximab, siltuximab and anakinra and anakinra treatment, two tubes of blood serum (5 ml) and four tubes of edta tube (10 ml) will be collected for measuring blood cytokine and chemokine levels, and activation of immune cells. also, an arterial blood gas determination via arterial puncture will be taken. on day 6, on day 15 (or on discharge, whichever is first) two tubes of blood serum (5ml) and four tubes of edta tube (10 ml) will be collected for measuring blood cytokine and chemokine levels, and activation of immune cells. also, an arterial blood gas determination via arterial puncture will be taken. on days 1, patients in various groups will receive single iv injection of sylvant® 11mg/kg or roactemra® 8mg/kg (max dose 800 mg), on top of standard of care. on days 1-28, (or until hospital discharge, whichever comes first), some patients in groups will additionally receive daily injection of 100 mg kineret® subcutaneously. if kidney function falls below 30 ml/min gfr, dosing needs to be adjusted to 100mg once every other day (q2d). on a final clinical visit between week 10-20 two additional serum tube (5ml) and four edta tubes (10 ml) will be taken. 1. patient demographics age, sex, day of admission, date of randomisation, date of discharge 2. day of covid-19 positivity, and conversion to negative test if available 3. patient biometry weight, length, bmi 4. clinical and laboratory parameters on screening day and during trial -first day of illness (upper airway symptoms, fever, dyspnea) , potential source of infection -clinical examination findings (cyanosis, crepitation's and rales, heart murmurs, peripheral edema) -vital signs (temperature, blood pressure, heart rate, breathing rate) -pulse oximetry data (sao2) -clinical blood gas sampling (pao2, paco2, hco3) measured in prone position while breathing room air -clinical chemistry sampling (ferritin, procalcitonin levels (daily), leukocyte formula, platelets, kidney and liver function, d-dimers, triglycerides) -chest x-ray and/or ct characteristics and radiology clinical report -in case of admission to icu : invasive monitoring data (arterial blood pressure, pcwp, continuous o2 saturation, continuous ecg, ventilatory parameters (tidal volume, fio2, peep pressure, peak pressure, minute ventilation) -mortality and date of death 5. all standard care drugs used during the trial and on day of enrolment of the trial, including oxygen flow rate. 6. basic clinical data on prior medical history (prior lung diseases, smoking history, prior lung function measurements (preferentially within 5 preceding years), prior gas exchange measurements and medication use will be collected from electronic medical record. 7. status of the patient on the 6 level ordinal scale needs to be assessed and recorded every day 8. study specific measurements (see table) . the ecrf will be checked as to ensure that all data needed to assess the secondary endpoints are collected. there are no subject restrictions during this trial. 9. sampling 9.1. types and number of samples d1: serum blood sample 2x 5ml, and optional edta blood sample, 4 x 10 ml d6: serum blood sample 2x5ml, and optional edta blood sample, 4 x 10 ml d15 or at discharge : serum blood sample 2x5ml, and optional edta blood sample, 4x10 ml w10-20 follow-up visit :serum blood sample 2x5ml, optional edta blood sample, 4 x 10 ml these samples are to be taken on d1, d6 and d15 and/or discharge and on final follow up visit between week 10 and 20. there's no time window allowed. 2 serum samples (2x5 ml) will be taken during hospitalization together with the blood draw for standard of care on day 1, 6 and 15 or hospital discharge and safety follow up visit. after clotting for 30-60 minutes the samples will be processed at 1500rpm or 410 g during 10 minutes at room temperature. 6 aliquots per time point will be filled and frozen at -80°c until further analysis. centrifugation and storage will be done by qualified personal at the various labs of the study centers. multiple cytokines (including il-1 and il-6 and chemokines will be measured by multiplex bead based elisa assay.) this will be performed by a single central lab, at a time point decided by the coordinating principle investigator, after consulting with the other investigators. samples will be shipped from the centers to the central lab, upon request of the coordinating principle investigator. in selected centers (to be decided by the local investigator after consulting with the coordinating principle investigator), additional 4x10 ml edta blood tubes will be taken at day 1, 6 and 15, or at hospital discharge and safety follow-up, for flow cytometric analysis and local research purposes. the investigators will purify peripheral blood mononuclear cells (pbmc) by gradient centrifugation. results of these trial will be shared with the coordinating principle investigator after analysis. amongst other, we propose to explore potentially key immunological parameters before and weekly after initiation of experimental therapy to determine 1) their relationship with diseases severity and patient characteristics; 2) their modifications by experimental therapy; 3) their relationship with clinical outcome. the proposal is based on the use of systems biology to 1) explore immunological parameters that cannot be predicted by current knowledge of the immunopathology of the disease; 2) integrate large numbers of parameters in order to be able to identify the most strongly associated with clinical parameters and with the therapeutic intervention. flow cytometry will be performed on paraformaldehyde fixed samples. for uz gent, this will be done by flanders institute of biotechnology (vib), in one of their laboratories based at uz ghent. transcriptional program of immune cell populations: edta blood samples will be processed to purify peripheral blood mononuclear cells and stained for flow cytometric analysis of number of monocytes, hla-dr expression on monocytes and dendritic cells, and lymphocyte activation. whole blood rna sequencing will be performed to globally assess differences in transcriptional programing of immune cells between patients and modifications following therapy. these data will be used to identify most discordant patient groups and time points on which single cell rna sequencing (cite-seq) will be conducted. on some samples at uzgent for example, a panel of 300 monoclonal antibodies coupled to oligonucleotides, developed by martin guilliams at vib, will be used to identify and phenotype and immune cell populations that will be further analyzed for their transcriptional program, in collaboration with ido amit, weizmann institute. in selected centres such as uz ghent, the plasma fraction of the edta blood tube after purification of the pbmc's will be used to measure sars-cov-2 rna using quantitative q-rt-pcr. at uz ghent for example, this will be optimized by the virology lab of prof. linos vandekerckhove at uz gent and correlated if possible with viral load determined by nasopharyngeal swab detection on d1 and d6 (for patients simultaneously enrolled in the observational co-vim trial in uz ghent). aliquots of left-over serum will be used for a systems analysis of covid-19 antibodies: biophysical (subclasses, fc glycosylation) and functional properties (macrophage and neutrophil phagocytosis, nk cell activation, complement activation, infection enhancement) of covid-19 specific igg and iga will be assessed. a systems serology platform has been established at the institute for medical immunology, ulb, in collaboration with galit alter, rago institute, and margaret ackerman, dartmouth college. serum samples and frozen pbmcs will be stored at fagg-certified biobank facilities of the participating research centres. storage conditions: -80°c 9.5. future use of stored samples initially samples will be stored for the use as described within this protocol. if at a later time point samples will be stored for future use, they will be stored in fagg certified biobank. statistical considerations the study was powered to detect the two main effects of the 2x2 factorial design, assuming there is no effect modification (no interaction between the different treatments). the first main effect relates to the comparison of il6 blockers (sylvant® and toclizumab groups combined) with usual care (2:1). to achieve at least 80% power to detect an improvement in median time to clinical improvement from 12 days to 8 days (corresponding to a hazard ratio of 1.5) at a twosided significance level of 5%, assuming an allocation ratio of 1:2, we need 215 events (i.e. clinical improvements of at least 2 points on the ordinal scale). with an accrual period of 8 weeks and a followup period for the last patient of 28 days, we would need 333 patients to observe 215 events, assuming 30% of patients are not susceptible to clinical improvement. the second main effect relates to the comparison of the il1 blocker (anakinra) with usual care (1:2). to achieve at least 80% power to detect an improvement in median time to clinical improvement from 12 days to 8 days (corresponding to a hazard ratio of 1.5) at a two-sided significance level of 5%, assuming an allocation ratio of 2:1, we need 215 events (i.e. clinical improvement of 2 points on the ordinal scale). with an accrual period of 8 weeks and a follow-up period for the last patient of 28 days, we would need 342 patients to observe at least 215 events, assuming 30% of patients are not susceptible to clinical improvement. the total number of patients needed to recruit within 8 weeks is 342 patients. sample size calculations were performed using r version 3.6.1 (2019-07-05) with the nsurvival function from the "gsdesign" package. primary analysis for each of the two main comparisons, the primary analysis is based on the primary endpoint defined as time from randomisation until either an improvement of two points on the six-category ordinal scale (defined above) or discharge from the hospital. patients who died before having experienced a 2-point improvement will be censored at the longest observed follow-up time seen in the study. if a patient dies after having had clinical improvement, we will consider this patient as a patient who reached the event of clinical improvement. kaplan-meier estimates of improvement-free survival curves will be compared between treatment groups with the log-rank test. the cumulative improvement rate will be plotted as a function of observation time. in addition, stratified cox proportional hazards regression models for time to clinical improvement (expressed in days) will be fitted with treatment group (il6-blocking treatment versus usual care or anakrina versus usual care ) as fixed effect. all models will be stratified by center, to allow for a different baseline hazard for clinical improvement at each center. the hazards ratio with 95% confidence interval will be estimated from this model. the proportional hazards assumption for the treatment effect will be checked by visual inspection of the log-log survival curves estimated nonparametrically. primary analysis will be according to the intention-to-treat principle, including all patients randomized and where patients allocated to a treatment group will be analyzed as members of that group irrespective of their compliance to the planned course of treatment. all analyses will be performed using r software. the survival analyses will be done using the "survival" package. given the short duration of the study (8 weeks for recruitment + 28 days for follow-up of the last patient), no interim analyses are planned. biostatistics unit, faculty of medicine and health science, ghent university 11. data handling 11 .1. method of data collection subjects that are included in the study, will be assigned a unique study number upon their registration in redcap. on all documents submitted to the coordinating center, sponsor or ci, patients will only be identified by their study number. the subject identification list will be safeguarded by the site. the name and any other directly identifying details will not be included in the study database. an electronic data capture (edc) system, i.e. redcap, will be used for data collection. data reported on each ecrf should be consistent with the source data. if information is not known, this must be clearly indicated on the ecrf. all missing and ambiguous data will be clarified. only the data required by the protocol are captured in the ecrf. the ecrfs and the database will be developed, based on the protocol. the final ecrf design will be approved by the co-ordinating investigator. all data entries and corrections will only be performed by study site staff, authorized by the investigator. data will be checked by trained personnel (monitor, data manager) and any errors or inconsistencies will be clarified. the investigator must verify that all data entries in the ecrf are accurate and correct. redcap is provided and maintained by vanderbilt university; a license for use was granted to the health, innovation and research institute (hiruz). redcap is a web-based system. the study site staff is responsible for data entry in redcap. n.a. the data is accessed through a web browser directly on the secure redcap server. the server is hosted within the uz ghent campus and meets hospital level security and back-up requirements. privacy and data integrity between the user's browser and the server is provided by mandatory use of transport layer security (tls), and a server certificate issued by terena (trans-european research and education networking association). all study sites will have access to redcap. site access is controlled with ip restriction. the investigator and sponsor specific essential documents will be retained for at least 25 years. at that moment, it will be judged whether it is necessary to retain them for a longer period, according to applicable regulatory or other requirement(s). direct access will be granted to authorised representatives from the sponsor, host institution and the regulatory authorities to permit study-related monitoring, audits and inspections. login in redcap is password controlled. each user will receive a personal login name and password and will have a specific role which has predefined restrictions on what is allowed in redcap. furthermore, users will only be able to see data of subjects of their own site. any activity in the software is traced and transparent via the audit trail and log files. after the completion of the study the sponsor will transfer the pseudonymized study data set to kce. kce will request approval from the competent chamber of the information security committee to have the relevant study data linked with ima data by a trusted third party (ttp, ehealth platform) using the patient national number. the patient information and consent includes wording that the national number will be recorded on site by the investigator for later data linkage. the patient information and consent will also include that in case the patient is randomized, it is planned that a trusted third party (ttp, ehealth platform) will receive and use the national number to link with ima administrative data. this data linkage is planned to obtain a more complete data set that will be used for the analysis of effectiveness and costeffectiveness of the intervention by kce. kce and sponsor have entered into a research agreement detailing the roles and responsibilities of each party, as well as other legal aspects of this collaboration, including the right to use and access of kce to the study data. "background" means any intellectual property (ip), data, materials, information owned or controlled by the sponsor or a site, and required to run this study. sponsor will identify such background including the legal restrictions of which sponsor or sites are aware that may affect the use of the background for the purpose of the study or the rights granted to kce under this agreement. the study data consist of this protocol, including amendments, the electronic forms for data capture, including the annotations and guidance for use, the electronic database of the pseudonymized clinical and non-clinical data collected using data capture, including the log of changes from data entry to database lock, study reports based on these pseudonymized data, and any data or reports generated at a later stage, eg based on exploratory analyses or stored samples. "foreground" means any study data, and any tangible biological, chemical and physical material and inventions, that are generated, acquired, discovered, conceived, developed, created, exemplified or derived as a result of carrying out the clinical study, whatever its form or nature, whether it can be protected or not, as well as any foreground ip. sponsor acknowledges that the main purpose of the research performed under this agreement is to generate results that will serve the general public interests, and specifically the interests of the patients and public healthcare decision making bodies, and, therefore, undertakes not to exploit the foreground in any way that is or could be detrimental to such interests. the sponsor owns the study data, but provides kce with a copy of the pseudonymized database after database lock as well as a royalty-free unrestricted license to use the study data for non-commercial public health related purposes as detailed in the agreement between kce and uz gent. if judged appropriate, kce will introduce the request to the competent chamber of the information security committee and arrange for the data linkage. for the sake of clarity, the linked data are not part of the study data. however, kce will discuss with the sponsor the results of the analyses and the reporting of the linked data. 12. safety any untoward medical occurrence in a subject to whom a medicinal product has been administered, including occurrences which are not necessarily caused by or related to that product. an adverse event, the nature or severity of which is not consistent with the applicable product information (e.g., investigator's brochure for an unapproved investigational product or package insert/summary of product characteristics for an approved product). adverse reaction (ar) an untoward and unintended response in a subject to an investigational medicinal product which is related to any dose administered to that subject. the phrase "response to an investigational medicinal product" means that a causal relationship between a study medication and an ae is at least a reasonable possibility, i.e. the relationship cannot be ruled out. all cases judged by either the reporting medically qualified professional or the sponsor as having a reasonable suspected causal relationship to the study medication qualify as adverse reactions. a serious adverse event is any untoward medical occurrence that: • results in death • is life-threatening • requires inpatient hospitalisation or prolongation of existing hospitalisation • results in persistent or significant disability/incapacity • consists of a congenital anomaly or birth defect other 'important medical events' may also be considered serious if they jeopardise the subject or require an intervention to prevent one of the above consequences. note: the term "life-threatening" in the definition of "serious" refers to an event in which the subject was at risk of death at the time of the event; it does not refer to an event which hypothetically might have caused death if it were more severe. an adverse event that is both serious and, in the opinion of the reporting investigator, believed with reasonable probability to be due to one of the study treatments, based on the information provided. a serious adverse reaction, the nature and severity of which is not consistent with the information about the medicinal product in question set out: • in the case of a product with a marketing authorisation, in the summary of product characteristics (smpc) for that product • in the case of any other investigational medicinal product, in the investigator's brochure (ib) relating to the study in question attribution definitions an adverse event is considered associated with the use of the drug if the attribution is possible, probable or definitive. an adverse event which is not related to the use of the drug. an adverse event for which an alternative explanation is more likely -e.g. concomitant drug(s), concomitant disease(s), and/or the relationship in time suggests that a causal relationship is unlikely. an adverse event which might be due to the use of the drug. an alternative explanation -e.g. concomitant drug(s), concomitant disease(s), -is inconclusive. the relationship in time is reasonable; therefore the causal relationship cannot be excluded. an adverse event which might be due to the use of the drug. the relationship in time is suggestive (e.g. confirmed by dechallenge). an alternative explanation is less likely -e.g. concomitant drug(s), concomitant disease(s). an adverse event which is listed as a possible adverse reaction and cannot be reasonably explained by an alternative explanation -e.g. concomitant drug(s), concomitant disease(s). the relationship in time is very suggestive (e.g. it is confirmed by dechallenge and rechallenge). ae's will be recorded from randomisation until the end of the study, as defined in section 4.2. special attention will be given to those subjects who have discontinued the study for an ae, or who experienced a severe or a serious ae. all ae's should be recorded in the patient's file and in the crf. sae's occurring during the entire study period will be reported as below. all serious adverse events (initial and follow up information) and pregnancies occurring during this study must be reported by the local principal investigator within 24 hours after becoming aware of the sae to: -the local ethics committee (it is the responsibility of the local pi to report the local sae's to the local ec) -hiruz ctu of the university hospital ghent -the national coordinating investigator (in case of multicenter studies) this reporting is done by using the appropriate sae form. for the contact details, see below. in case the coordinating investigator, in consultation with hiruz ctu, decides the sae is a susar (suspected unexpected serious adverse reaction), hiruz ctu will report the susar to the central ec  hiruz ctu will submit to the central ec.  hiruz ctu will submit to the famhp  study team informs company that provides the imp in case the (su)sar occurs at a local participating site, the local pi or study team should also contact: -the local ethics committee -the co-ordinating investigator 12.5. events, excluded from reporting covid-19 infection is a very recent syndrome, on which few data are available. normal symptoms and natural disease course symptoms that will not be reported as adverse events are dyspnea, coughing, malaise, fever, drop in oxygen saturation, progression to respiratory failure, progression to ards, drop in blood pressure, progression to multi-organ failure. all study medication is registered and used in current practice. despite the known safety profile of the study medications and study design, a dsmb is foreseen. the coordinating investigator will provide dsurs once a year throughout the clinical study, or on request, to the competent authority (famhp in belgium), ethics committee and sponsor. this dsur will include all sae's (who were not categorized as sar's and were not immediately reported to the ec). the report will be submitted within 60 days after the start of the study, and will subsequently be submitted each year until the study is declared ended. hiruz ctu can provide a template that can be used to complete this dsur. 13. monitoring/auditing/inspection 13.1. monitoring monitoring of the study will be performed in compliance with gcp e6(r2) and the applicable regulatory requirements. the study team will be trained in an initiation visit by the monitor. a training and delegation log will be held. a detailed description of the monitoring tasks can be found in the latest version of the (study-specific) 'monitoring plan'. monitoring services will be provided by hiruz ctu. all relevant contact details (e.g. primary contact person, can be found in the 'monitoring plan'. monitoring services will consist of the following (non-exhaustive list): -review of informed consents and the followed process -check on recruitment status -checking for protocol deviations/violations -checking gcp compatibility -check on safety reporting compliance -imp handling and storage -review of study data … this study can be inspected at any time by regulatory agencies during or after completion of the study. therefore access to all study records, including source documents, must be accessible to the inspection representatives. subject privacy must be respected at all times, in accordance to gdpr, gcp and all other applicable local regulations. the investigator/study team should immediately notify the sponsor if he or she has been contacted by a regulatory agency concerning an upcoming inspection. sponsor and all investigators agree to take any reasonable actions to correct protocol deviations/violations noted during monitoring/inspection, in consultation with the monitoring team. all deviations must be documented on a protocol deviation log by the study team that is kept available at any time for monitoring/inspection purposes. under emergency circumstances, deviations from the protocol to protect the rights, safety or well-being of human subjects may proceed without prior approval of the sponsor and the ec. critical issues that significantly affect patient safety, data integrity and/or study conduct should be clearly documented and will be communicated with the coordinating investigator, hiruz ctu and possibly both the applicable ethics committee(s) and competent authority. (please contact hiruz ctu asap in case of a serious breach: hiruz.ctu@uzgent.be and/or +3293320500). early determination of the study (in a specific center or overall) may be necessary in case of major noncompliance. 14. ethical and legal aspects the study will be conducted cfr the latest version of the ich e6 (r2) gcp guidelines, creating a standard for the design, conduct, performance, monitoring, auditing, recording, analyses and reporting of clinical studies that provides assurance that the data and reported results are accurate and that the rights, integrity and confidentiality of study subjects are protected. eligible subjects may only be included in the study after providing written (witnessed, if needed) ethics committee-approved informed consent, or, if incapable of doing so, after such consent has been provided by a legally acceptable representative(s) of the subject. informed consent must be obtained before conducting any study-specific procedures (as described in this protocol). prior to entry in the study, the investigator must explain to potential subjects or their legal representatives the study and the implication of participation. subjects will be informed that their participation is voluntary and that they may withdraw consent to participate at any time. participating subjects will be told that their records may be accessed by competent authorities and by authorized persons without violating the confidentiality of the subject, to the extent permitted by the applicable law(s) and/or regulations. by signing the informed consent form (icf), the subjects or legally acceptable representatives are authorizing such access. after this explanation and before entry to the study, written, dated and signed informed consent should be obtained from the subject or legally acceptable representative. the icf should be provided in a language sufficiently understood by the subject. subjects must be given the opportunity to ask questions. the subject or legally acceptable representative will be given sufficient time to read the icf and to ask additional questions. after this explanation and before entry to the study, consent should be appropriately recorded by means of either the subject's or his/her legal representative's dated signature or the signature of an independent witness who certifies the subject's consent in writing. after having obtained the consent, a copy of the icf must be given to the subject. in case the subject or legally acceptable representative is unable to read, an impartial witness must attest the informed consent. subjects who are unable to comprehend the information provided or pediatric subjects can only be enrolled after consent of a legally acceptable representative. the protocol has been reviewed and approved by the ethics committee of the ghent university (hospital), designated as the central ethics committee, after consultation with the local ethics committees, and the federal agency for medicine and health products (famhp). this study cannot start before both approvals have been obtained. subjects have completed the study, a notification of the end of the study should be submitted to the (central) ethics committee and famhp. this notification should be made within 90 days of the end of the clinical study risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease clinical features of patients infected with 2019 novel coronavirus in wuhan interleukin-1 receptor blockade is associated with reduced mortality in sepsis patients with features of macrophage activation syndrome: reanalysis of a prior phase iii trial siltuximab for multicentric castleman's disease: a randomised, double-blind, placebo-controlled trial covid-19: consider cytokine storm syndromes and immunosuppression the use of anti-inflammatory drugs in the treatment of people with severe coronavirus disease 2019 (covid-19): the experience of clinical immunologists from china clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan new therapeutic opportunities for covid-19 patients with tocilizumab: possible correlation of interleukin-6 receptor inhibitors with osteonecrosis of the jaws who r&d blueprint informal consultation on teh potential role of il-6/il-1 antagonists in teh clinical management of covid-19 infection th17 responses in cytokine storm of covid-19: an emerging target of jak2 inhibitor fedratinib pathological findings of covid-19 associated with acute respiratory distress syndrome screening follow-up (10x --------------------------------------→ x ecg 1 x ----------------------------→ x arterial blood gas x 1 x 2 x 2 x 2 x 2 x 2 chest x-ray or ct scan 1 °as soon as all in-and exclusion criteria are checked and patient is considered eligible, patient can be randomized in ivrs. this is allowed the day before d1 in order to make practical arrangements to start treatment. 1 per standard of care, information to be collected if available. 2 mandatory: patient in upright position, after minimal 3 minutes without supplemental oxygen. in case of inability to sit upright: same position is to be used for all measurements of pao2. in ventilated patients or ecmo patients pao2 can be taken from invasive arterial line and fio2 taken directly from mechanical ventilation settings. 3 patients randomized in the treatment group will receive anakinra: sc treatment for 28 days (or until hospital discharge whichever comes first), alone or in combination with tocilizumab: single iv injection on day 1 or siltuximab: single iv injection on day 1. some patients will only receive tocilizumab: single iv injection on day1; some patients will only receive siltuximab: single iv injection on day 1. 4 only amendments that are intended to eliminate an apparent immediate safety threat to patients may be implemented immediately. notwithstanding the need for approval of formal protocol amendments, the investigators are expected to take any immediate action, required for the safety of any subject included in this study, even if this action represents a deviation from the protocol. these actions should always be notified to the sponsor. all study data will be handled in accordance with the law on general data protection regulation (gdpr) and institutional rules [belgian law dated on 30 july 2018 and 22 aug. 2002].the collection and processing of personal data from subjects enrolled in this study will be limited to those data that are necessary to fulfil the objectives of the study. these data must be collected and processed with adequate precautions to ensure confidentiality and compliance with applicable data privacy protection laws and regulations.appropriate technical and organizational measures to protect the personal data against unauthorized disclosures or access, accidental or unlawful destruction, or accidental loss or alteration must be put in place. sponsor and site personnel whose responsibilities require access to personal data agree to keep the identity of subjects confidential. the informed consent obtained from the subject includes explicit consent for the processing of personal data and for the investigator/institution to allow direct access to his or her original medical records (source data/documents) for study-related monitoring, audit, ethics committee review and regulatory inspection. this consent also addresses the transfer of the data to other entities, if applicable.privacy and confidentiality of data generated in the future on stored samples will be protected by the same standards applicable to all other clinical data. stored samples will be pseudonymized throughout the sample storage and analysis process and will not be labelled with personal identifiers. the sponsor has taken a no fault insurance for this study, in accordance with the relevant legislation (article 29, belgian law of may 7, 2004 this study will be registered at clinicalstudies.gov, and results information from this study will be submitted to clinicalstudies.gov. in addition, every attempt will be made to publish results in peerreviewed journals.16. key: cord-349329-f0pbd968 authors: bosteels, cedric; maes, bastiaan; van damme, karel; de leeuw, elisabeth; declercq, jozefien; delporte, anja; demeyere, bénédicte; vermeersch, stéfanie; vuylsteke, marnik; willaert, joren; bollé, laura; vanbiervliet, yuri; decuypere, jana; libeer, frederick; vandecasteele, stefaan; peene, isabelle; lambrecht, bart title: sargramostim to treat patients with acute hypoxic respiratory failure due to covid-19 (sarpac): a structured summary of a study protocol for a randomised controlled trial date: 2020-06-05 journal: trials doi: 10.1186/s13063-020-04451-7 sha: doc_id: 349329 cord_uid: f0pbd968 objectives: the hypothesis of the proposed intervention is that granulocyte-macrophage colony-stimulating factor (gm-csf) has profound effects on antiviral immunity, and can provide the stimulus to restore immune homeostasis in the lung with acute lung injury post covid-19, and can promote lung repair mechanisms, that lead to a 25% improvement in lung oxygenation parameters. sargramostim is a man-made form of the naturally-occurring protein gm-csf. trial design: a phase 4 academic, prospective, 2 arm (1:1 ratio), randomized, open-label, controlled trial. participants: patients aged 18-80 years admitted to specialized covid-19 wards in 5 belgian hospitals with recent (< 2 weeks prior to randomization) confirmed covid-19 infection and acute respiratory failure defined as a pao2/fio2 below 350 mmhg or spo2 below 93% on minimal 2 l/min supplemental oxygen. patients were excluded from the trial in case of (1) known serious allergic reactions to yeast-derived products, (2) lithium carbonate therapy, (3) mechanical ventilation prior to randomization, (4) peripheral white blood cell count above 25.000/μl and/or active myeloid malignancy, (5) high dose systemic steroid therapy (> 20 mg methylprednisolone or equivalent), (6) enrolment in another investigational study, (7) pregnant or breastfeeding or (8) ferritin levels > 2000 μg/ml. intervention and comparator: inhaled sargramostim 125 μg twice daily for 5 days in addition to standard care. upon progression of disease requiring mechanical ventilation or to acute respiratory distress syndrome (ards) and initiation of mechanical ventilator support within the 5 day period, inhaled sargramostim will be replaced by intravenous sargramostim 125 μg/m(2) body surface area once daily until the 5 day period is reached. from day 6 onwards, progressive patients in the active group will have the option to receive an additional 5 days of iv sargramostim, based on the treating physician's assessment. intervention will be compared to standard of care. subjects progressing to ards and requiring invasive mechanical ventilatory support, from day 6 onwards in the standard of care group will have the option (clinician's decision) to initiate iv sargramostim 125m μg/m(2) body surface area once daily for 5 days. main outcomes: the primary endpoint of this intervention is measuring oxygenation after 5 days of inhaled (and intravenous) treatment through assessment of a change in pretreatment and post-treatment ratio of pao2/fio2 and through measurement of the p(a-a)o2 gradient (pao2= partial alveolar pressure of oxygen, pao2=partial arterial pressure of oxygen; fio2= fraction of inspired oxygen). randomisation: patients will be randomized in a 1:1 ratio. randomization will be done using redcap (electronic iwrs system). blinding (masking): in this open-label trial neither participants, caregivers, nor those assessing the outcomes will be blinded to group assignment. numbers to be randomised (sample size): a total of 80 patients with confirmed covid-19 and acute hypoxic respiratory failure will be enrolled, 40 in the active and 40 in the control group. trial status: sarpac protocol version 2.0 (april 15 2020). participant recruitment is ongoing in 5 belgian hospitals (i.e. university hospital ghent, az sint-jan bruges, az delta roeselare, university hospital brussels and zna middelheim antwerp). participant recruitment started on march 26(th) 2020. given the current decline of the covid-19 pandemic in belgium, it is difficult to anticipate the rate of participant recruitment. trial registration: the trial was registered on clinical trials.gov on march 30(th), 2020 (clinicaltrials.gov identifier: nct04326920) retrospectively registered; https://clinicaltrials.gov/ct2/show/nct04326920?term=sarpac&recrs=ab&draw=2&rank=1 and on eudract on march 24th, 2020 (identifier: 2020-001254-22). full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. the primary objective is to investigate whether the administration of inhaled sargramostim (leukine®) at a dose of 250 mcg daily during 5 days improves oxygenation in covid-19 patients with acute hypoxic respiratory failure. the secondary objectives are: -to study if early intervention with sargramostim is safe (number of aes/saes) -to study if early intervention with inhaled sargramostim affects clinical outcome defined by duration of hospital stay, 6-point ordinal scale, clinical sign score, sofa score, news2 score -to study if early intervention with sargramostim affects the rate of nosocomial infection -to study if early intervention with inhaled sargramostim affects progression to mechanical ventilation and/or ards -to study if treatment with sargramostim affects all-cause mortality rate at 4 and 20 weeks post inclusion -to study if treatment with sargramostim affects features of secondary haemophagocytic lymphohistiocytosis, defined by hs score -to study if treatment with sargramostim has a favourable effect on long term 10-20 week follow up 1.4. subjects 1.4.1. number of subjects a total of 80 patients with confirmed covid-19 and acute hypoxic respiratory failure will be enrolled, 40 in the active and 40 in the control group. confirmed covid-19 patients with acute hypoxic respiratory failure admitted to the covid-19 isolation ward. inclusion and exclusion criteria the following patients will be enrolled: -recent (≤2weeks prior to randomization) confident diagnosis of covid-19 confirmed by antigen detection and/or pcr, and/or seroconversion or any other emerging and validated diagnostic test. -in some patients, it may be impossible to get a confident laboratory confirmation of covid-19 diagnosis after 24h of hospital admission because viral load is low and/or problems with diagnostic sensitivity. in those cases, in absence of an alternative diagnosis, and with highly suspect bilateral ground glass opacities on recent (<24h) chest-ct scan (confirmed by a radiologist and pulmonary physician as probable covid-19), a patient can be enrolled as probable covid-19 infected. in all cases, this needs confirmation by later seroconversion. -presence of acute hypoxic respiratory failure defined as (either or both)  saturation below 93% on minimal 2 l/min o2  pao2/fio2 below 350 -admitted to specialized covid-19 ward -age 18-80 -male or female -willing to provide informed consent exclusion criteria -patients with known history of serious allergic reactions, including anaphylaxis, to human granulocyte-macrophage colony stimulating factor such as sargramostim, yeast-derived products, or any component of the product. -mechanical ventilation before start of study -patients with peripheral white blood cell count above 25.000 per microliter and/or active myeloid malignancy -patients on high dose systemic steroids (> 20 mg methylprednisolone or equivalent) -patients on lithium carbonate therapy -patients enrolled in another investigational drug study -pregnant or breastfeeding females (all female subjects regardless of childbearing potential status must have negative pregnancy test at screening) -patients with serum ferritin >2000 mcg/ml (which will exclude ongoing hlh) 1.6. study interventions confirmed or highly suspect covid-19 patients with acute hypoxic respiratory failure (saturation below 93% on minimal 2 l/min o2 or pao2/fio2 <350) will be randomized to receive sargramostim 125mcg twice daily for 5 days as a nebulized inhalation on top of standard of care (active group), or to receive standard of care treatment (control group). upon progression of disease requiring initiation of mechanical ventilatory support within the 5 day period, in patients in the active group, inhaled sargramostim will be replaced by intravenous sargramostim 125mcg/m 2 body surface area once daily until the 5 day period is reached. from day 6 onwards, progressive patients in the active group will have the option to receive an additional 5 days of iv sargramostim, based on the treating physician's assessment. in the control group with progressive disease requiring mechanical ventilatory support, from day 6 onwards, the treating physician will have the option to initiate iv sargramostim 125mcg/m 2 body surface area once daily for 5 days. safety data, including blood leukocyte counts, will be collected in all patients. efficacy data will also be collected and will include arterial blood gases, oxygenation parameters, need for ventilation, lung compliance, organ function, radiographic changes, ferritin levels, triglyceride levels, etc. as well as occurrence of secondary bacterial infections. patients will stop the investigational drug if there is unacceptable toxicity according to investigator's judgement. 13/49 1.6.1. imps and dosage leukine® (sargramostim) prepared and administered for inhalation using nebulizer leukine for injection is a sterile, preservative-free lyophilized powder that requires reconstitution with 2ml normal saline solution. once reconstituted, leukine can be inhaled as an aqueous aerosol using either a vibrating mesh nebulizer (philips innospirego) or jet nebulizer, per manufacturer instructions. (nebulizers studied include: akita2 apixneb, pari lc-plus set, pulmoaide, pan lc, aeroneb solo device). use reconstituted leukine® solution for inhalation within 16 hours following reconstitution and/or dilution. nebulizing is preferably done in an isolation negative pressure chamber, and if not, personnel should use an ffp2 mask. patient should self-administer the medication and where possible, the room should not be entered within one hour after administration. for patients that are on a mechanical ventilator and cannot be treated with leukine® inhalation:  the recommended dose is 125 mcg/m 2 /day administered intravenously over a 4-hour period once daily for up to 5 days.  for intravenous injection: administer leukine injection in 0.9% sodium chloride injection, usp. dilute leukine for intravenous infusion in 0.9% sodium chloride injection, usp. if the final concentration of leukine is below 10 mcg/ml, add albumin (human) at a final concentration of 0.1% to the saline prior to addition of leukine to prevent adsorption to the components of the drug delivery system. to obtain a final concentration of 0.1% albumin (human), add 1 mg albumin (human) per 1 ml 0.9% sodium chloride injection, usp (e.g., use 1 ml 5% albumin [human] in 50 ml 0.9% sodium chloride injection, usp). 1.6.2. schematic overview of the data collection & interventions 1.7. study duration the total treatment duration of the study is 10 days, and the entire study duration is 10-22 weeks to final follow up visit. sargramostim (leukine®) is a yeast-derived recombinant humanized granulocyte-macrophage colony stimulating factor (rhugm-csf, sargramostim) and the only fda approved gm-csf (leucine package insert). gm-csf, a pleiotropic cytokine, is an important leukocyte growth factor known to play a key role in haematopoiesis, effecting the growth and maturation of multiple cell lineages as well as the functional activities of these cells in antigen presentation and cell mediated immunity (1). since its initial fda approval in 1991, over 500,000 patients have received leukine®, providing extensive clinical and post-marketing data in a broad range of treated individuals -from preterm neonates to the elderly and including males and females -representing a well-characterized safety profile for leukine®. leukine® administered as a subcutaneous or intravenous injection is approved for six indications including use as a medical countermeasure for radiation exposure. the us government currently holds leukine® in the strategic national stockpile. leukine® may benefit patients with beginning signs of acute respiratory distress syndrome (ards) due to covid-19 infection. gm-csf is a critical cytokine for the health of lungs. the alveolar macrophages are dependent on gm-csf for differentiation and normal functioning. in addition, gm-csf is an immunomodulator that plays a critical role in host defense by promoting differentiation of dendritic cells, and stimulating antiviral immunity (2-4). as described in detail below, it is being studied as an adjuvant therapy in the management of lifethreatening infections to boost the hosts innate immune response to fight infection, reduce the risk of secondary infection, and in varied conditions to prevent infection during critical illness (5) (6) (7) (8) . in addition, it has been studied in pulmonary conditions that affect alveolar macrophages, such as autoimmune pulmonary alveolar proteinosis ("apap"), with beneficial outcomes (9, 10) . we propose based on preclinical and clinical data and the safety data from more than 500,000 adult and pediatric patients treated with leukine®, that patients with beginning signs of acute lung injury and/or ards due to covid-19 infection be given leukine®. ards due to covid-19 carries a high mortality rate (11) and leukine® may confer benefit by both active management of this complication as well as in prevention of secondary infections. in animal models of postviral ards and mortality, gm-csf has demonstrated immunomodulatory effects that improve the clinical response and symptoms associated with influenza and other viral respiratory infections (12) (13) (14) , and represents a promising candidate for the prevention of ards in patients with covid-19. the proposed development plan was guided by three specific considerations: the biology and effects of gm-csf on the lung, specifically alveolar macrophages and epithelial cells, as well its immunomodulatory activities in stimulating antiviral immunity make gm-csf a critical cytokine for healthy pulmonary function and defence. detailed studies have shown that gm-csf is necessary for the maturation of alveolar macrophages from fetal monocytes and the maintenance of these cells in adulthood (1). gm-csf has a wide array of effects on myeloid cells. gm-csf has been shown to be a myelopoietic growth factor that has pleiotropic effects not only in promoting the differentiation of immature precursors into polymorphonuclear neutrophils, monocytes/ macrophages and dendritic cells, but also in controlling the function of fully mature myeloid cells (15) . gm-csf is also known to reverse immunoparalysis seen in sepsis by immune activation, resulting in beneficial outcomes (5). there is a large body of evidence generated with gm-csf in animal studies suggesting the potential use in ards and infections (16) . for the purpose of brevity, we will point to the data that reflects the potential value in viral lung infections and preventing secondary bacterial infections and progression to ards: halstead and colleagues demonstrated that in vivo high airway levels of gm-csf profoundly rescue mice from lethal influenza pneumonia. while in vitro gm-csf is canonically described as an m1polarizing cytokine, their data demonstrated that in vivo, during influenza a virus infection, gm-csf instead temporizes the type ii interferon-induced m1 polarization of airway macrophages and reduces inflammation induced damage (12, 13) . unkel and colleagues demonstrated gm-csf-dependent cross-talk between influenza virus infected alveolar epithelial cells and cd103+ dendritic cells is crucial for effective viral clearance and recovery from injury and thus pointing to the potential use of gm-csf treatment in severe influenza virus pneumonia (17) . investigations have shown that gm-csf conferred resistance to influenza in mice via alveolar phagocytes and through alveolar macrophages which became more resistant to influenza-induced apoptosis. delivery of intranasal gm-csf to wild-type mice also conferred resistance to influenza (18) . there is evidence that inhaled gm-csf prevents bacteremia in post influenza bacterial pneumonia primarily through locally-mediated improved lung antibacterial resistance to systemic bacteremia during influenza a viral infection (13) . conclusions: gm-csf confers resistance to influenza by enhancing innate immune mechanisms that depend on alveolar macrophages, which are dependent on gm-csf for their health and normal functioning. pulmonary delivery of this cytokine has the potential to reduce morbidity and mortality due to viral pneumonia. this is summarized in the diagram below: 18/49 2. experience: use of leukine® has beneficial effect in the treatment of conditions that are similar to ards seen with covid-19. a small (18 patient) double blind randomized placebo controlled clinical trial of low-dose (3mcg/kg daily for 5 days) intravenous gm-csf treatment in adult patients with severe sepsis and respiratory dysfunction, led to the conclusion that gm-csf treatment was associated with improved gas exchange and might play a homeostatic role (6) . in a phase ii study, 130 patients with severe sepsis with respiratory dysfunction were randomized to gm-csf (250mcg/m 2 intravenously daily for 14days) or placebo. the results showed an improvement in 28day mortality on gm-csf; this did not reach statistical significance due to the small sample size (7). herold and colleagues used leukine® by inhalation route on a compassionate basis in six patients with moderate to severe community-acquired pneumonia or ventilator-associated pneumonia ards who were not improving despite all measures and at least 6 days of mechanical ventilation (8) . 125mcg of leukine® were applied by aeroneb solo device (covidien, neustadt, germany) at an interval of 48 hours. compared to historical controls, the authors observed significant improvement in oxygenation and lung compliance with gm-csf therapy. this resulted in improved morbidity using standard scoring systems and 4 of the six patients recovered and were discharged from the hospital. there is an ongoing study of inhaled gm-csf across multiple centers in germany (gi hope; nct02595060) recruiting patients with diagnosis of pneumonia associated ards. there is a large body of evidence of inhaled leukine® in autoimmune pulmonary alveolar proteinosis (apap), which results in accumulation of surfactant in alveolar sacs with resultant hypoxia. tazawa and colleagues conducted a phase ii study of inhaled leukine® at 9 pulmonary centers throughout japan in patients with unremitting or progressive apap with hypoxia and symptoms (9) . patients received 250mcg daily by inhalation, using an lc-plus nebulizer with a manual interrupter valve connected to a pari turbo boy compressor, for 7 days and this cycle was repeated every other week for six cycles (total 12 weeks). the treatment was well tolerated with no serious adverse events. adverse events were reported in just 7 of the 39 patients oxygenation, radiological changes as well as symptoms. following these results, a larger randomized phase 3 study (page study) was conducted by the japanese investigators in 12 centers. 64 patients with mild to moderate apap with hypoxia were randomized to receive placebo or leukine® (33 patients) at a dose of 125mcg twice a day for 7days followed by a week of no treatment. this two-week cycle was repeated 12 times over a period of 24 weeks. the treatment was again well tolerated with no significant differences in adverse events between the two groups. the gm-csf treated patients had significantly improved hypoxia parameters and radiographic changes (10) . this clinical experience of use of leukine® in viral pneumonia suggests salutary effects. in addition, these studies establish the safety of inhaled leukine® and provide evidence for activity of inhaled leukine®. 3. expediency: toxicology, pharmacologic and safety data supports the immediate clinical use of leukine® in hypoxic respiratory failure with acute lung injury leading to ards due to covid-19. investigator brochure is available and contains detailed information on toxicity. risk/benefit assessment covid-19 poses a very significant risk of mortality of 3-7% and this percentage rises to mortality of 20% in patients with co-morbidity (11, 19) . of all infected patients, some 15-20% develop severe respiratory symptoms necessitating hospital admission. around 5% of infected patients will require invasive mechanical ventilation, and many of those (40-50% will die). the current world-wide pandemic of covid-19 is putting unforeseen stress on the entire primary, secondary and tertiary medical system, leading to unseen triage of patients that potentially benefit or not from admission to icu units when they develop respiratory failure. gm-csf (sargramostim, leukine®) has been given systemically to almost 500.000 patients in the past. it is therefore a well characterized product. inhalation of gm-csf has also been used to treat patients with interstitial lung disease and reduced oxygen saturation (i.e. partial acute hypoxic respiratory failure) with few significant side effects above the placebo arm. the protocol is set up to give twice daily inhalation with gm-csf, followed by intravenous administration if the patient would move to the icu unit on mechanical ventilation. although gm-csf has been given systemically and via inhalation to patients with pneumoniaassociated ards, there are no current data on the safety profile of this drug in patients with covid-19. given the severity of the clinical syndrome caused by covid-19, and the prior triage of patients before hospital admission to the covid-19 ward, this trial will be performed in a hospital setting on a covid-19 ward with close monitoring of vital parameters (continuous ecg, oxygen saturation, temperature, vital clinical signs), which will allow intermediate intervention should serious side effects occur. once on the icu unit, patients will be intensively monitored for all vital parameters, as part of the routine icu monitoring. there are currently no treatments directed at improving lung repair and local immunity in covid-19 patients, and no treatment that attempt to halt the progression from manageable acute hypoxic respiratory failure to ards. preventing such progression to ards could have a huge impact on the foreseeable overflow of the icu units. we therefore believe the benefits of administering inhaled gm-csf treatment in early stage covid-19 acute hypoxic respiratory failure outweighs the risks associated with a phase 4 imp administration via a different route and unknown indication. there is a large number of covid-19 infected patients that are currently being hospitalized across the globe. in just 9 days time, our covid-19 ward at ghent university hospital has admitted 25 confirmed cases, of which a significant portion (50%) already fulfill eligibility criteria for the current proposed protocol. we therefore believe that given the current ascending part of the epidemiology curve, with numbers of patients rising sharply, there will be no shortage of patients that are eligible. partner therapeutics has offered to give (free of charge) enough gm-csf to treat 20 patients for a 10 day period and an additional 20 controls for 5 days (should deterioration occur). there are large 20/49 amounts of gm-csf in the united states strategic national stockpile, so should this therapy work, there might be immediate worldwide application of a gm-csf inhalation therapy. primary objectives this is phase 4 academic, prospective, randomized, open-label, interventional study designed to investigate the efficacy of sargramostim (leukine®) in improving oxygenation and short-and long-term outcome of covid-19 patients with acute hypoxic respiratory failure. there are currently no treatments directed at improving lung repair and local immunity in covid-19 patients, and no treatment that attempt to halt the progression from manageable acute hypoxic respiratory failure to ards in patients with covid-19 infection. justification for our objective is that preventing progression from early acute hypoxic respiratory failure to ards could have a huge impact on the foreseeable overflow of the icu units, that is already happening in some countries and is bound to happen on a global scale. the outcome of our study could thus have large impact from a medical, ethical and economic perspective. the hypothesis of the proposed intervention is that gm-csf has profound effects on antiviral immunity, can provide the stimulus to restore immune homeostasis in the lung with acute lung injury post covid-19, and can promote lung repair mechanisms, that lead to a 25% improvement in lung oxygenation parameters. this hypothesis is based on experiments performed in mice showing that gm-csf treatment can prevent mortality and prevent ards in mice with post-viral acute lung injury. to address our hypothesis, we will randomize patients with confirmed covid-19 with acute hypoxic respiratory failure (saturation below 93% on minimal 2 l/min o2 or pao2/fio2 <350) to receive sargramostim 125mcg twice daily for 5 days as a nebulized inhalation on top of standard of care (active group), or to receive standard of care treatment (control group). upon progression of disease requiring initiation of non-invasive or invasive mechanical ventilatory support within the 5 day period, in patients in the active group, inhaled sargramostim will be replaced by intravenous sargramostim 125mcg/m 2 body surface area once daily until the 5 day period is reached. to measure the effectiveness of sargramostim on restoring lung homeostasis, the primary endpoint of this intervention is measuring oxygenation after 5 days of inhaled (and intravenous) treatment through assessment of pretreatment and post-treatment ratio of pao2/fio2 and through measurement of the p(a-a)o2 gradient, which can easily be performed in the setting of clinical observation of patients admitted to the covid -19 ward or icu covid-19 unit. during the 5 day treatment period, we will perform daily measurements of oxygen saturation (pulse oximetry) in relation to fio2, and the slope of alterations in these parameters could also be an indicator that our hypothesis is correct. comparison will be between active group a receiving sargramostim on top of standard of care and control group b receiving standard of care. data from the wuhan covid-19 epidemic show that patients that deteriorate are facing a prolonged period of mechanical ventilation. therefore, from day 6 onwards, progressive patients in the active group will have the option to receive an additional 5 days of iv sargramostim, based on the treating physician's assessment. this group will be called group c. in the control group, for patients with 21/49 progressive disease requiring (non)-invasive mechanical ventilatory support, from day 6 onwards, the treating physician will have the option to initiate iv sargramostim 125mcg/m 2 body surface area once daily for 5 days. this group will be called group d. comparisons of group a (early 5 day intervention with sargramostim) with group d (late 5 day intervention with sargramostim) will also be very informative. secondary objectives -to study if early intervention with sargramostim is safe (number of aes/saes) -to study if early intervention with inhaled sargramostim affects clinical outcome defined by duration of hospital stay, mean change in 6-point ordinal scale between day 1 and day 6 mean change in clinical sign score between day 1 and day 6 time to clinical sign score <6 maintained for 24h mean change of sofa score between day 1 and day 6 or between day 1 and day 11. mean change news2 score score between day 1 and day 6 or between day 1 and day 11. tine to news2 score less than 2 for at least 24h to measure the effectiveness of sargramostim on restoring lung homeostasis, the primary endpoint of this intervention is measuring oxygenation after 5 days of inhaled (and intravenous) treatment through assessment of pretreatment (day 0) and post-treatment (day 5) ratio of pao2/fio2 and through measurement of the p(a-a)o2 gradient, which can easily be performed in the setting of clinical observation of patients admitted to the covid -19 ward or icu covid-19 unit. preferentially, this measurement should be done in the upright position, while breathing room air for a minimum of 3 minutes.. if this is impossible due to need for supplemental oxygen, fio2 and oxygen supplementation method should be recorded in patient record, so that a-a gradient can be normalized for age expected normal a-a gradient while on supplemental oxygen use. during the 5 day treatment period, we will perform daily measurements of oxygen saturation (pulse oximetry) in relation to fio2, and the slope of alterations in this parameters could also be an indicator that our hypothesis is correct. if the patient leaves hospital prior to the day 6 analysis point, oxygenation at day of discharge will be used as value for measuring primary endpoint. -to study if early intervention with sargramostim is safe (number of aes/saes) although sargramostim has been given previously by inhalation to patients with ards and interstitial lung disease, data on safety in patients with covid-19 infection are currently lacking. since we are randomizing against 5 days of no sargramostim treatment, comparison of aes and saes between group a and group b will be very informative. -to study if early intervention with inhaled sargramostim affects clinical outcome defined by length of hospital stay mean change in 6-point ordinal scale change between day 1, day 6 and -to study if early intervention with sargramostim affects the rate of nosocomial infection patients with viral respiratory infection are at risk of secondary bacterial infections. as part of routine clinical care, sputum samples will be collected in patients suspected of secondary bacterial pneumonia, and checked for the presence of bacteria. -to study if early intervention with inhaled sargramostim affects progression to mechanical ventilation and/or ards decreasing oxygenation often leads to the need for non-invasive or invasive mechanical ventilation, and if severe enough to a diagnosis of ards. we will therefore as a secondary endpoint also study if early intervention with inhaled sargramostim prevents progression to criteria-defined ards (according to the american-european consensus conference (aecc) diagnostic criteria for ards: acute onset; ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (pao2/fio2) of 200 or less, regardless of positive end-expiratory pressure; bilateral infiltrates seen on frontal chest radiograph; and pulmonary artery wedge pressure of 18 mm hg or less when measured, or no clinical evidence of left atrial hypertension), requiring high-flow oxygen devices, non-invasive mechanical ventilation, mechanical ventilation, by measuring the day from admission when this diagnosis is made or therapies are initiated. -to study if treatment with sargramostim affects all-cause mortality rate at 4 and 20 weeks post inclusion. -to study if treatment with sargramostim affects features of secondary haemophagocytic lymphohistiocytosis. a large subset of patients with severe covid-19 developing respiratory failure might have a cytokine storm syndrome, designated as secondary haemophagocytic lymphohistiocytosis (shlh). shlh is an under-recognised, hyperinflammatory syndrome characterised by a fulminant and fatal hypercytokinemia with multi-organ failure. cardinal features of shlh include unremitting fever, cytopenias, and hyperferritinaemia; hypertriglyceridemia, pulmonary involvement can present as ards. a cytokine profile resembling shlh is associated with covid-19 disease severity, characterised by increased interleukin (il)-2, il-7, granulocyte-colony stimulating factor, interferon-γ inducible protein 10, monocyte chemoattractant protein 1, macrophage inflammatory protein 1-α, and tumour necrosis factor-α. predictors of fatality from a recent retrospective, multicentre study of 150 confirmed covid-19 cases in wuhan, china, included elevated ferritin (mean 1297·6 ng/ml in non-survivors vs 614·0 ng/ml in survivors; p<0·001) and il-6 (p<0·0001), suggesting that mortality might be due to virally driven hyperinflammation. to address the effect of sargramostim treatment on shlh, we will measure levels of ferritin, these chemokines and cytokines at the beginning of the trial day 0 and after the initial 5 day treatment. pbo including leukocytes and lymphocytes are performed on a routine clinical basis in these patients. -to study if treatment with sargramostim has a favourable effect on long term 10-20 week follow up at 10-20 weeks after discharge from hospital, patients will be seen on routine check-up by pulmonologist, who will perform a clinical exam, pulmonary function tests (including fvc, tlc and diffusion capacity), and a laboratory (ferritin, lymphocytes, leukocytes). this is phase 4 academic, prospective, randomized, open-label, interventional study designed to investigate the efficacy of sargramostim (leukine®) in improving oxygenation and short-and long-term outcome of covid-19 patients with acute hypoxic respiratory failure. there are currently no treatments directed at improving lung repair and local immunity in covid-19 patients, and no treatment that attempt to halt the progression from manageable acute hypoxic respiratory failure to ards in patients with covid-19 infection. justification for our objective is that preventing progression from early acute hypoxic respiratory failure to ards could have a huge impact on the foreseeable overflow of the icu units, that is already happening in some countries and is bound to happen on a global scale. the hypothesis of the proposed intervention is that gm-csf has profound effects on antiviral immunity, can provide the stimulus to restore immune homeostasis in the lung with acute lung injury post covid-19, and can promote lung repair mechanisms, that lead to a 25% improvement in lung oxygenation parameters. this hypothesis is based on experiments performed in mice showing that gm-csf treatment can prevent mortality and prevent ards in mice with post-viral acute lung injury. we will randomize patients with confirmed covid19 with acute hypoxic respiratory failure (saturation below 93% on minimal 2 l/min o2 or pao2/fio2 <350) to receive sargramostim 125mcg twice daily for 5 days as a nebulized inhalation on top of standard of care (active group), or to receive standard of care treatment (control group). upon progression of disease to requiring invasive mechanical ventilatory support within the 5 day period, in patients in the active group, inhaled sargramostim will be replaced by intravenous sargramostim 125mcg/m 2 body surface area until the 5 day period is reached. dosing of inhaled and systemic sargramostim are based on prior experience of this drug in patients with pulmonary alveolar proteinosis (inhaled) and with pneumonia associated ards (inhaled and intravenous). the inhaled route is preferred first, because high local concentrations of gm-csf have a favourable effect on lung immunity, lung homeostasis and lung repair. the switch to intravenous treatment with deterioration requiring initiation of mechanical ventilation is necessitated by the fact that patients with covid-19 poorly tolerate ventilation in the absence of high level positive end expiratory pressure (peep), especially when they develop ards. for giving the sargramostim via inhalator in a ventilated patient, this would involve peep-free ventilation for at least 10-15 minutes, which will not be tolerated in covid-19 associated severe hypoxic respiratory failure and/or ards according to expert opinion (prof. dr. pieter depuydt, intensive care unit, uz ghent). to measure the effectiveness of sargramostim on restoring lung homeostasis, the primary endpoint of this intervention is measuring oxygenation after 5 days of inhaled (and intravenous) treatment through assessment of pretreatment and post-treatment ratio of pao2/fio2 and through measurement of the p(a-a)o2 gradient, which can easily be performed in the setting of clinical observation of patients admitted to the covid -19 ward or icu covid-19 unit. supplemental oxygen use will be recorded, and if needed a-a gradient will be normalized against expected age-and supplemental oxygen dependent a-a gradient. during the 5 day treatment period, we will perform daily measurements of oxygen saturation (pulse oximetry) in relation to fio2, and the slope of alterations in this parameters could also be an indicator that our hypothesis is correct. if the patient leaves hospital prior to the day 6 analysis point, oxygenation at day of discharge will be used as value for measuring primary endpoint. comparison will be between active group a receiving sargramostim on top of standard of care and control group b receiving standard of care. data from the wuhan covid-19 epidemic show that patients that deteriorate are facing a prolonged period of mechanical ventilation. therefore, from day 6 onwards, progressive patients in the active group will have the option to receive an additional 5 days of iv sargramostim, based on the treating physician's assessment. this group will be called group c. in the control group with progressive disease requiring invasive mechanical ventilatory support or developing ards, from day 6 onwards, the treating physician will have the option to initiate iv sargramostim 125mcg/m 2 body surface area once daily for 5 days. this group will be called group d. comparisons of group a (early 5 day intervention with sargramostim) with group d (late 5 day intervention with sargramostim) will also be very informative. the subject has completed the study if he or she has completed all phases of the study, including the last visit (week 10-20 clinical follow up visit) or the last scheduled procedures, as described in this protocol (see section "9. study specific procedures"). overall, the end of the study is reached when the last study procedure for the last subject has occurred: last subject, last visit (lslv). as soon as the whole study has ended (cfr. the definition above), the co-ordinating investigator shall notify the hiruz clinical trial unit, so that the competent authority and the ethics committee can be informed in a timely manner according to the regulatory requirements (within 90 days after end of the study, or if the study had to be terminated early, this period must be reduced to 15 days and the reasons should clearly explained). there is a large number of covid-19 infected patients that are currently being hospitalized across the globe. in just 9 days time, our covid-19 ward at ghent university hospital has admitted 25 confirmed cases, of which a significant portion (50%) already fulfill eligibility criteria for the current proposed protocol. we therefore believe that given the current ascending part of the epidemiology curve, with numbers of patients rising sharply, there will be no shortage of patients that are eligible. we estimate the study to terminate in 30 weeks, including last clinical follow up visits. the following patients will be enrolled recent (≤2weeks prior to randomization) -confident covid-19 diagnosis confirmed by antigen detection test and/or pcr and/or positive serology, or any emerging and validated diagnostic laboratory test for covid-19 within this period. -in some patients, it may be impossible to get a confident laboratory confirmation of covid-19 diagnosis after 24h of hospital admission because viral load is low and/or problems with diagnostic sensitivity. in those cases, in absence of an alternative diagnosis, and with highly suspect bilateral ground glass opacities on recent (<24h) chest-ct scan (confirmed by a radiologist and pulmonary physician as probable covid-19), a patient can be enrolled as probable covid-19 infected. in all cases, this needs confirmation by later seroconversion. -presence of acute hypoxic respiratory failure defined as (either or both) saturation below 93% on minimal 2 l/min o2 pao2/fio2 below 350 -admitted to specialized covid-19 ward -age 18-80 -male or female -willing to provide informed consent -patients with known history of serious allergic reactions, including anaphylaxis, to human granulocytemacrophage colony stimulating factor such as sargramostim, yeast-derived products, or any component of the product. -mechanical ventilation before start of study -patients enrolled in another investigational drug study -pregnant or breastfeeding females (all female subjects regardless of childbearing potential status must have negative pregnancy test at screening) -patients with peripheral white blood cell count above 25.000 per microliter and/or active myeloid malignancy -patients on high dose systemic steroids (> 20 mg methylprednisolone or equivalent) -patients on lithium carbonate therapy -patients with serum ferritin >2000 mcg/ml (which will exclude ongoing hlh) 27/49 6.2.1. screen failures screen failures are defined as subjects who consent to participate in the clinical study but are not subsequently randomly assigned to the study intervention or entered in the study. a minimal set of screen failure information will be kept to ensure transparent reporting of screen failure subjects. there is a large number of covid-19 infected patients that are currently being hospitalized across the globe. in just 9 days time, our covid-19 ward at ghent university hospital has admitted 25 confirmed cases, of which a significant portion (50%) already fulfill eligibility criteria for the current proposed protocol. similar numbers of patients are currently being seen in all centers.. we therefore believe that given the current ascending part of the epidemiology curve, with numbers of patients rising sharply, there will be no shortage of patients that are eligible. the number of subjects that will be included in this study is: 80. these are divided into following sub-groups: group a : active sargramostim treatment group, treatment for initial 5 days, no deterioration after 5 days number of patients : 40 group b : control group : no treatment with sargramostim in first 5 days number of patients : 40 group c and d : data from the wuhan covid-19 epidemic show that patients that deteriorate are facing a prolonged period of mechanical ventilation. therefore, from day 6 onwards, progressive patients in the active group will have the option to receive an additional 5 days of iv sargramostim sargramostim 125mcg/m2 body surface area once daily, based on the treating physician's assessment. this group will be called group c. it is estimated that some 30% of patients might deteriorate and require noninvasive or invasive mechanical ventilation, giving potentially rise to 12 patients that progress from group a to group c, if the clinician decides to move forward with the drug. in the control group progressing to requiring invasive or non-invasive mechanical ventilatory support, from day 6 onwards, the treating physician will have the option to initiate iv sargramostim 125mcg/m 2 body surface area once daily for 5 days. this group will be called group d. it is estimated that some 30% of patients might deteriorate to mechanical ventilation or ards, giving potentially rise to 12 patients that progress from group a to group c, if the clinician decides to move forward with the drug comparisons between group a (early sargramostim) versus group b (no sargramostim) at day 6 will be important for reaching primary endpoint, and for key secondary endpoints. comparisons of group a (early 5 day intervention with sargramostim) with group d (late 5 day intervention with sargramostim) will also be very informative for secondary endpoint analysis. subjects are free to withdraw from participation in the study at any time upon request. an investigator may discontinue or withdraw a subject from the study for the following reasons: • allergic reactions (anaphylactic shock) to sargramostim • pregnancy  progression to non-invasive or invasive mechanical ventilation and/or ards between screening and randomization • significant study intervention non-compliance • if any clinical adverse event (ae), laboratory abnormality, or other medical condition or situation occurs such that continued participation in the study would not be in the best interest of the subject • if the subject meets an exclusion criterion (either newly developed or not previously recognized) that precludes further study participation in all cases, the reason why subjects are withdrawn must be recorded in detail in the ecrf and in the subject's medical records. if a patient decides to leave hospital before day 6 of the study, for example because of clinical improvement, the oxygenation parameters at day of discharge will be used to calculate the primary endpoint measurement. the following actions must be taken if a subject fails to return to the clinic for a required study visit (visit at 10-20 weeks post end of study) : • the site will attempt to contact the subject and reschedule the missed visit within 4 weeks and counsel the subject on the importance of maintaining the assigned visit schedule and ascertain if the subject wishes to and/or should continue in the study. • before a subject is deemed lost to follow-up, the investigator or designee will make every effort to regain contact with the subject (where possible, 3 telephone calls and, if necessary, a certified letter to the subject's last known mailing address or local equivalent methods). these contact attempts should be documented in the subject's medical record or study file. • should the subject continue to be unreachable, he or she will be considered to have withdrawn from the study with a primary reason of lost to follow-up. subjects will be recruited at the covid-19 hospitalization ward at the participating centers. the study will be proposed by the treating physician to all subjects with pcr-confirmed covid-19 infection and a presence of acute hypoxic respiratory failure. there will be no compensation for study participation. partner therapeutics inc. is providing sargramostim to the study subjects, free of charge. since this is a hospital based trial, taking place over a minimum of five days in which patients are severely ill, we suspect the retention in the trial to be high. patients will be informed about the study by the treating physician. after receiving full explanation, having received sufficient time to considerer the trial, asking questions and receiving satisfying responses to all questions, patients will be asked to sign icf. a serum pregnancy test will be done (female patients only). medical history will be checked for review of exclusion criteria and relevant subject information. patients will be continuously monitored on the covid-19 ward. exams (standard of care) include, but are not limited to: -ecg -chest x-ray, and ct-scan -laboratory tests for leukocyte formula, kidney and liver function, ferritin levels -vital signs -pulse oximetry, arterial blood gas, capnography as soon as all in-and exclusion criteria are checked and patient is considered eligible, patient can be randomized. there is no minimal window to randomize the patient. the producer and distributor of leukine® is partner therapeutics inc, an integrated commercial-stage biotech company focused on the development and commercialization of therapeutics that improve health outcomes in the treatment of cancer. the distribution of imp will be done by tanner pharma. for inhalation: leukine® is a sterile, preservative-free lyophilized powder that requires reconstitution with 4ml normal saline solution, to reach a concentration of 62,5 mcg/ml. once reconstituted, leukine® can be inhaled as an aqueous aerosol using either a vibrating mesh nebulizer or jet nebulizer, aerosolizing 2 ml twice daily. reconstituted leukine® solution for inhalation should be used within 16 hours following reconstitution and/or dilution. dosage for inhalation: 125mcg twice daily via nebulizer. nebulizing is preferably done in an isolation negative pressure chamber, and if not, personnel should use an ffp2 mask. patient should self-administer the medication and where possible, the room should not be entered within one hour after administration. for intravenous injection: leukine® injection in 0.9% sodium chloride injection, usp. dilute leukine® for intravenous infusion in 0.9% sodium chloride injection, usp. if the final concentration of leukine® is below 10 mcg/ml, add albumin (human) at a final concentration of 0.1% to the saline prior to addition of leukine to prevent adsorption to the components of the drug delivery system. to obtain a final concentration of 0.1% albumin (human), add 1 mg albumin (human) per 1 ml 0.9% sodium chloride injection, usp (e.g., use 1 ml 5% albumin [human] in 50 ml 0.9% sodium chloride injection, usp). once diluted for infusion, leukine® is stable for 6h. dosage for intravenous injection: 125mcg/m 2 /day over a 4-hour period for up to 5 days. no dose adjustments and interruptions are permitted during this trial. in case of anaphylaxis or severe ae, the drug will be immediately interrupted. leukine® will be administered for 5 days, with a possible 5 day extension to a maximum of 10 days in case of progression of disease and need for mechanical ventilation. 8.1.6. packaging and labeling of the imp leukine® (sargramostim) for injection is a sterile, preservative-free, white lyophilized powder supplied in a carton containing five 250 mcg single-dose vials. leukine® (sargramostim) injection is a sterile, clear, colorless solution preserved with 1.1% benzyl alcohol supplied in a carton containing one 500 mcg/ml multiple-dose vial and a carton containing five 500 mcg/ml multiple-dose vials (ndc 0024-5844-05). storage and handling : leukine should be stored at 4 °c. drug will be labeled by pharmacy uz ghent (for uz ghent enrolment) for inhaled or intravenous use. store leukine® vials refrigerated at 2°c-8°c (36°f-46°f) in the original carton to protect from light. do not freeze or shake. do not use beyond the expiration date printed on the vial. leukine® is to be shipped refrigerated at 2°c-8°c (36°f-46°f). the medication will be delivered to the pharmacy of the participating centers. temperature during shipment and storage is to be monitored continuously. whenever a temperature deviation occurs, partner therapeutics inc. should be contacted. partner therapeutics inc. might allow further use of the medication vials depending on the duration and intensity of the temperature excursion. the co-ordinating investigator should be informed of this deviation as well. to date, there have been no new safety signals associated with leukine® (sargramostim). observed side effects with aerosolized leukine® at 250mcg dose and in at least one evaluation have included: bronchospasm, cough, dyspnea, a decrease in vital capacity and/or forced expiratory volume associated with bilateral infiltrates, pleural effusions, increased phlegm, throat irritation, and back pain. there are no restrictions regarding concomitant/rescue medication. patients will be informed about the study by the treating physician. after receiving full explanation, having received sufficient time to considerer the trial, asking questions and receiving satisfying responses to all questions, patients will be asked to sign icf. the icf process will be performed before any other study related procedure. in this open label trial patients will be randomized in a 1:1 ratio. randomization in belgium will be done using redcap (electronic ivrs system). this is a hospital based intervention trial, in which patients with covid-19 will be treated at least for 5 days with sargramostim. patients with covid-19 infection and respiratory failure are severely ill, and will require multiple daily clinical exams, blood sampling, vital parameter measurements, blood oxygenation measurements, and chest x-rays. these are all part of the clinical management plan of the patients, and data stored in the electronic patient file will be used as part of the assessment of efficacy and safety profile of sargramostim. on screening, blood sample will be taken, preferentially during routine blood sampling, to determine exclusion criteria (pregnancy, high ferritin level). on day 1, prior to sargramostim treatment in group a, and during the day in group b control patients, a tube of blood serum (5 ml) and an edta tube (10 ml) will be collected for measuring blood cytokine and chemokine levels, and activation of immune cells in selected centers. also in each center, an arterial blood gas determination via arterial puncture will be taken. this sample should be taken in an upright position, while breathing room air for a minimum of 3 minutes.. if this is impossible due to dependency on supplemental oxygen, fio2, oxygen flow rate, and method of oxygen delivery should be noted in the patient file. if arterial blood gas is taken within 24h before first dose administration, as described in point° the arterial blood gas of screening can be used as d1 value. on day 6 or on day of discharge before day 6 , a tube of blood serum (5ml) and an edta tube (10 ml) will be collected for measuring blood cytokine and chemokine levels, and activation of immune cells in selected centers. also in each center, an arterial blood gas determination via arterial puncture will be taken. on days 1-5, patients in group a will inhale sargramostim 125mcg twice daily for 5 days as a nebulized inhalation using a philips innospire go portable mesh nebulizer on top of standard of care. this device is a handheld mesh nebulizer that can be fitted with a facial mask. patients will be instructed prior to receiving the first dose on how to use this simple device, by a physician. this procedure is finished in 5-10 minutes, and will be performed twice daily, in the morning (between 6 a.m. and 11 a.m.) and evening (between 6 p.m. and 11 p.m.). upon progression of disease requiring initiation of invasive mechanical ventilatory support within the 5 day period, in patients in the active group, inhaled sargramostim will be replaced by intravenous sargramostim 125mcg/m 2 body surface area once daily until the 5 day period is reached. this administration will occur via a centrally placed catheter or peripheral catheter, that will be in place as part of routine medical care at the icu. on a final clinical visit between week 12-20 an additional serum tube (5ml) and an edta tube (10 ml) will be taken in selected centers. 1. patient demographics age, sex, ethnicity, day of admission 2. day of covid-19 pcr positivity, and conversion to negative 2. patient biometry weight, length, bmi, body surface area 3. clinical and laboratory parameters on screening day and during trial -first day of illness, potential source of infection -clinical examination findings (cyanosis, crepitation's and rales, heart murmurs, peripheral edema) -vital signs (temperature, blood pressure, heart rate, breathing rate) -pulse oximetry data (sao2) -clinical blood gas sampling (pao2, paco2, hco3) -clinical chemistry sampling (ferritin, leukocyte formula, platelets, kidney and liver function, fibrinogen, triglycerides) -chest x-ray and/or ct characteristics and radiology clinical report -in case of admission to icu : invasive monitoring data (arterial blood pressure, pcwp, continuous o2 saturation, continuous ecg, ventilatory parameters (tidal volume, fio2, peep pressure, peak pressure, minute ventilation) 4. all standard care drugs used during the trial and on day of enrolment of the trial, including oxygen flow rate. 5. basic clinical data on prior medical history (prior lung diseases, smoking history, prior lung function measurements (preferentially within 5 preceding years), prior gas exchange measurements) and medication use will be collected from electronic medical record. 6. study specific measurements 10. sampling in selected centers only: d1: serum blood sample 5ml, edta blood sample, 10 ml d6 or discharge before day 6 : serum blood sample 5ml, edta blood sample, 10 ml w10-20 follow-up visit : serum blood sample 5ml, edta blood sample, 10 ml these samples are to be taken on d1 and d6 (or discharge if before day 6) and on final follow up visit between week 10 and 20. there's no time window allowed. in selected centers samples will be taken during hospitalization together with the blood draw for standard of care. after clotting for 30-60minutes the samples will be processed at 1500rpm or 410 g during 10 minutes at room temperature. 3 aliquots will be filled and frozen at -80°c until further analysis. centrifugation and storage will be done by qualified personal. edta blood samples will be processed to purify peripheral bloodmonocytes and stained for flow cytometric analysis of number of monocytes, hla-dr expression on monocytes and dendritic cells, and lymphocyte activation. multiple cytokines and chemokines will be measured by multiplex bead based elisa assay. flow cytometry will be performed on paraformaldehyde fixed samples. development of anti-drug antibodies (ada) will be measured using protocol developed by partner therapeutics on serum samples taken at day 1 and follow up visit. serum samples and frozen pbmcs will be stored at temperature monitored facilities of the participating research centres. . storage conditions: -80°c. initially samples will be stored for the use as described within this protocol. if at a later time point samples will be stored for future use, they will be stored in fagg certified biobank the outcome(s) on which the sample size calculation is based upon, is the primary endpoint measurement of oxygenation, defined as ratio of pa02/fio2 and p(a-a)o2. sample calculation and power analysis have been performed using genstat. the target difference is the difference measured at the primary endpoint (at day 5) between the control and the treated group. given a sample size of 40 patients each, a minimal improvement of 10% in the treated group relative to the control group will be detected as significant at a significance level of 0,01 with a power of 0.90. the error variance was set at 100 units, corresponding with a standard deviation of 10 units. the statistical test to be used will be an f-test. a two-sample t-test is expected to give similar results. the statistical analysis will be performed by gnomixx, a biostatistics consultancy company based in ghent (dr marnik vuylsteke). http://www.gnomixx.com/ subjects that are included in the study , will be assigned a unique study number upon their registration in redcap.. on all documents submitted to the coordinating center, sponsor or ci, patients will only be identified by their study number. the subject identification list will be safeguarded by the site. the name and any other directly identifying details will not be included in the study database. an electronic data capture (edc) system, i.e. redcap, will be used for data collection. data reported on each ecrf should be consistent with the source data. if information is not known, this must be clearly indicated on the ecrf. all missing and ambiguous data will be clarified. only the data required by the protocol are captured in the ecrf. the ecrfs and the database will be developed, based on the protocol. the final ecrf design will be approved by the co-ordinating investigator. all data entries and corrections will only be performed by study site staff, authorized by the investigator. data will be checked by trained personnel (monitor, data manager) and any errors or inconsistencies will be clarified. the investigator must verify that all data entries in the ecrf are accurate and correct. redcap is provided and maintained by vanderbilt university; a license for use was granted to the health, innovation and research institute (hiruz). redcap is a web-based system. the study site staff is responsible for data entry in redcap. the data is accessed through a web browser directly on the secure redcap server. the server is hosted within the uz ghent campus and meets hospital level security and back-up requirements. privacy and data integrity between the user's browser and the server is provided by mandatory use of transport layer security (tls), and a server certificate issued by terena (trans-european research and education networking association). all study sites will have access to redcap. site access is controlled with ip restriction. the investigator and sponsor specific essential documents will be retained for at least 25 years. at that moment, it will be judged whether it is necessary to retain them for a longer period, according to applicable regulatory or other requirement(s). direct access will be granted to authorised representatives from the sponsor, host institution and the regulatory authorities to permit study-related monitoring, audits and inspections. login in redcap is password controlled. each user will receive a personal login name and password and will have a specific role which has predefined restrictions on what is allowed in redcap. furthermore, users will only be able to see data of subjects of their own site. any activity in the software is traced and transparent via the audit trail and log files. term definition adverse event (ae) any untoward medical occurrence in a subject to whom a medicinal product has been administered, including occurrences which are not necessarily caused by or related to that product. an adverse event, the nature or severity of which is not consistent with the applicable product information (e.g., investigator's brochure for an unapproved investigational product or package insert/summary of product characteristics for an approved product). adverse reaction (ar) an untoward and unintended response in a subject to an investigational medicinal product which is related to any dose administered to that subject. the phrase "response to an investigational medicinal product" means that a causal relationship between a study medication and an ae is at least a reasonable possibility, i.e. the relationship cannot be ruled out. all cases judged by either the reporting medically qualified professional or the sponsor as having a reasonable suspected causal relationship to the study medication qualify as adverse reactions. a serious adverse event is any untoward medical occurrence that:  results in death  is life-threatening  requires inpatient hospitalisation or prolongation of existing hospitalisation  results in persistent or significant disability/incapacity  consists of a congenital anomaly or birth defect other 'important medical events' may also be considered serious if they jeopardise the subject or require an intervention to prevent one of the above consequences. note: the term "life-threatening" in the definition of "serious" refers to an event in which the subject was at risk of death at the time of the event; it does not refer to an event which hypothetically might have caused death if it were more severe. an adverse event that is both serious and, in the opinion of the reporting investigator, believed with reasonable probability to be due to one of the study treatments, based on the information provided. a serious adverse reaction, the nature and severity of which is not consistent with the information about the medicinal product in question set out:  in the case of a product with a marketing authorisation, in the summary of product characteristics (smpc) for that product  in the case of any other investigational medicinal product, in the investigator's brochure (ib) relating to the study in question attribution definitions an adverse event is considered associated with the use of the drug if the attribution is possible, probable or definitive. an adverse event which is not related to the use of the drug. an adverse event for which an alternative explanation is more likely -e.g. concomitant drug(s), concomitant disease(s), and/or the relationship in time suggests that a causal relationship is unlikely. an adverse event which might be due to the use of the drug. an alternative explanation -e.g. concomitant drug(s), concomitant disease(s), -is inconclusive. the relationship in time is reasonable; therefore the causal relationship cannot be excluded. an adverse event which might be due to the use of the drug. the relationship in time is suggestive (e.g. confirmed by dechallenge). an alternative explanation is less likely -e.g. concomitant drug(s), concomitant disease(s). an adverse event which is listed as a possible adverse reaction and cannot be reasonably explained by an alternative explanation -e.g. concomitant drug(s), concomitant disease(s). the relationship in time is very suggestive (e.g. it is confirmed by dechallenge and rechallenge). ae's will be recorded from the first drug administration until the end of the study, as defined in section 5.2. special attention will be given to those subjects who have discontinued the study for an ae, or who experienced a severe or a serious ae. all ae's should be recorded in the patient's file and in the crf. sae's occurring during the entire study period will be reported as below. all serious adverse events (initial and follow up information) and pregnancies occurring during this study must be reported by the local principal investigator within 24 hours after becoming aware of the sae to: -the local ethics committee (it is the responsibility of the local pi to report the local sae's to the local ec) -hiruz ctu of the university hospital ghent -the national coordinating investigator (in case of multicenter studies) the company partner therapeutics that provides the imp this reporting is done by using the appropriate sae form. for the contact details, see below.  study team informs company that provides the imp susar notify to hiruz ctu within 24 hours after becoming aware of the susar  hiruz ctu will submit to the central ec.  hiruz ctu will submit to the famhp  study team informs company that provides the imp in case the (su)sar occurs at a local participating site, the local pi or study team should also contact: -the local ethics committee -the co-ordinating investigator 13.5. events, excluded from reporting covid-19 infection is a very recent syndrome, on which few data are available. normal symptoms and natural disease course symptoms that will not be reported as adverse events are dyspnea, coughing, malaise, fever, drop in oxygen saturation, progression to respiratory failure, progression to ards, severe drop in blood pressure in the icu,progression to multi-organ failure. all study medication is registered and used in current practice. despite the known safety profile of the study medications and study design, a dsmb is foreseen. the coordinating investigator will provide dsurs once a year throughout the clinical study, or on request, to the competent authority (famhp in belgium), ethics committee and sponsor. this dsur will include all sae's (who were not categorized as sar's and were not immediately reported to the ec). the report will be submitted within 60 days after the start of the study, and will subsequently be submitted each year until the study is declared ended. hiruz ctu can provide a template that can be used to complete this dsur. monitoring/auditing/inspection 14.1. monitoring monitoring of the study will be performed in compliance with gcp e6(r2) and the applicable regulatory requirements. the study team will be trained in an initiation visit by the monitor. a training and delegation log will be held. a detailed description of the monitoring tasks can be found in the latest version of the (study-specific) 'monitoring plan'. monitoring services will be provided by hiruz ctu. all relevant contact details (e.g. primary contact person, can be found in the 'monitoring plan'. monitoring services will consist of the following (non-exhaustive list): -review of informed consents and the followed process -check on recruitment status -checking for protocol deviations/violations -checking gcp compatibility -check on safety reporting compliance -imp handling and storage -review of study data … this study can be inspected at any time by regulatory agencies during or after completion of the study. therefore access to all study records, including source documents, must be accessible to the inspection representatives. subject privacy must be respected at all times, in accordance to gdpr, gcp and all other applicable local regulations. the investigator/study team should immediately notify the sponsor if he or she has been contacted by a regulatory agency concerning an upcoming inspection. sponsor and all investigators agree to take any reasonable actions to correct protocol deviations/violations noted during monitoring/inspection, in consultation with the monitoring team. all deviations must be documented on a protocol deviation log by the study team that is kept available at any time for monitoring/inspection purposes. under emergency circumstances, deviations from the protocol to protect the rights, safety or well-being of human subjects may proceed without prior approval of the sponsor and the ec. ethical and legal aspects 15 . the study will be conducted cfr the latest version of the ich e6 (r2) gcp guidelines, creating a standard for the design, conduct, performance, monitoring, auditing, recording, analyses and reporting of clinical studies that provides assurance that the data and reported results are accurate and that the rights, integrity and confidentiality of study subjects are protected. eligible subjects may only be included in the study after providing written (witnessed, if needed) ethics committee-approved informed consent, or, if incapable of doing so, after such consent has been provided by a legally acceptable representative(s) of the subject. informed consent must be obtained before conducting any study-specific procedures (as described in this protocol). prior to entry in the study, the investigator must explain to potential subjects or their legal representatives the study and the implication of participation. subjects will be informed that their participation is voluntary and that they may withdraw consent to participate at any time. participating subjects will be told that their records may be accessed by competent authorities and by authorized persons without violating the confidentiality of the subject, to the extent permitted by the applicable law(s) and/or regulations. by signing the informed consent form (icf), the subjects or legally acceptable representatives are authorizing such access. after this explanation and before entry to the study, written, dated and signed informed consent should be obtained from the subject or legally acceptable representative. the icf should be provided in a language sufficiently understood by the subject. subjects must be given the opportunity to ask questions. the subject or legally acceptable representative will be given sufficient time to read the icf and to ask additional questions. after this explanation and before entry to the study, consent should be appropriately recorded by means of either the subject's or his/her legal representative's dated signature or the signature of an independent witness who certifies the subject's consent in writing. after having obtained the consent, a copy of the icf must be given to the subject. in case the subject or legally acceptable representative is unable to read, an impartial witness must attest the informed consent. subjects who are unable to comprehend the information provided or pediatric subjects can only be enrolled after consent of a legally acceptable representative. any significant change or addition to the protocol can only be made in a written protocol amendment that must be approved by the central ethics committee (and the famhp if applicable). only amendments that are intended to eliminate an apparent immediate safety threat to patients may be implemented immediately. notwithstanding the need for approval of formal protocol amendments, the investigators are expected to take any immediate action, required for the safety of any subject included in this study, even if this action represents a deviation from the protocol. these actions should always be notified to the sponsor. all study data will be handled in accordance with the law on general data protection regulation (gdpr) and institutional rules [belgian law dated on 30 july 2018 and 22 aug. 2002]. the collection and processing of personal data from subjects enrolled in this study will be limited to those data that are necessary to fulfill the objectives of the study. these data must be collected and processed with adequate precautions to ensure confidentiality and compliance with applicable data privacy protection laws and regulations. appropriate technical and organizational measures to protect the personal data against unauthorized disclosures or access, accidental or unlawful destruction, or accidental loss or alteration must be put in place. sponsor and site personnel whose responsibilities require access to personal data agree to keep the identity of subjects confidential. the informed consent obtained from the subject includes explicit consent for the processing of personal data and for the investigator/institution to allow direct access to his or her original medical records (source data/documents) for study-related monitoring, audit, ethics committee review and regulatory inspection. this consent also addresses the transfer of the data to other entities, if applicable. privacy and confidentiality of data generated in the future on stored samples will be protected by the same standards applicable to all other clinical data. stored samples will be pseudonymized throughout the sample storage and analysis process and will not be labeled with personal identifiers. the sponsor has taken a no fault insurance for this study, in accordance with the relevant legislation (article 29, belgian law of may 7, 2004 critical issues that significantly affect patient safety, data integrity and/or study conduct should be clearly documented and will be communicated with the coordinating investigator, hiruz ctu and possibly both the applicable ethics committee(s) and competent authority. (please contact hiruz ctu asap in case of a serious breach: hiruz early determination of the study (in a specific center or overall) may be necessary in case of major noncompliance. 15.6. end of study notification if all subjects have completed the study, a notification of the end of the study should be submitted to the (central) ethics committee and famhp. this notification should be made within 90 days of the end of the clinical study the cloning of gm-csf alveolar macrophages develop from fetal monocytes that differentiate into long-lived cells in the first week of life via gm-csf gm-csf treatment prevents respiratory syncytial virus-induced pulmonary exacerbation responses in postallergic mice by stimulating alveolar macrophage maturation yolk sac macrophages, fetal liver, and adult monocytes can colonize an empty niche and develop into functional tissue-resident macrophages a review of gm-csf therapy in sepsis a randomized phase ii trial of granulocyte-macrophage colony-stimulating factor therapy in severe sepsis with respiratory dysfunction a randomized trial of recombinant human granulocyte-macrophage colony stimulating factor for patients with acute lung injury inhaled granulocyte/macrophage colony-stimulating factor as treatment of pneumonia-associated acute respiratory distress syndrome inhaled granulocyte/macrophage-colony stimulating factor as therapy for pulmonary alveolar proteinosis inhaled gm-csf for pulmonary alveolar proteinosis pathological findings of covid-19 associated with acute respiratory distress syndrome gm-csf overexpression after influenza a virus infection prevents mortality and moderates m1-like airway monocyte/macrophage polarization lower respiratory tract delivery, airway clearance, and preclinical efficacy of inhaled gm-csf in a postinfluenza pneumococcal pneumonia model lung epithelial gm-csf improves host defense function and epithelial repair in influenza virus pneumonia-a new therapeutic strategy? the pleiotropic effects of the gm-csf rheostat on myeloid cell differentiation and function: more than a numbers game frontline science: coincidental null mutation of csf2ralpha in a colony of pi3kgamma-/-mice causes alveolar macrophage deficiency and fatal respiratory viral infection alveolar epithelial cells orchestrate dc function in murine viral pneumonia gm-csf in the lung protects against lethal influenza infection pulmonary pathological features in coronavirus associated severe acute respiratory syndrome (sars) screening follow-up (10-20 weeks after d1) d1 d5 d6 (or discharge before day 6 ) informed consent x inclusion/exclusion criteria check serum pregnancy test x vital signs (incl. height and weight)* ° this sample should be taken in an upright position, while breathing room air for a minimum of 3 minutes.. if this is impossible due to dependency on supplemental oxygen, fio2, oxygen flow rate, and method of oxygen delivery should be noted in the patient file. § if arterial blood gas is taken within 24h before first dose administration, as described in point° the arterial blood gas of screening can be used as d1 value ∞ patients randomized in the treatment group will receive inhaled sargramostim from d1 untill d5. in case of progression requiring mechanical ventilation within the first 5 days, iv sargramostim can be initiated until the 5 day period is reached. from day 6 onwards, progressive patients in the active group will have the option to receive an additional 5 days of iv sargramostim, based on the treating physician's assessment. patients in the control group will have the option to receive 5 days of iv sargramostim in case of progression requiringmechanical ventilation, based on the treating physician's assessment.order of assessments: imp should always be administered after other assessments, where possible. there are no subject restrictions during this trial.in case the coordinating investigator, in consultation with hiruz ctu, decides the sae is a susar (suspected unexpected serious adverse reaction), hiruz ctu will report the susar to the central ec and the famhp within the timelines as defined in national legislation. the coordinating investigator reports the susar to all local pi's. in case of a life-threatening and fatal susar the entire reporting process must be completed within 7 calendar days. in case of a non life-threatening susar the reporting process must be completed within 15 calendar days. notify to hiruz ctu within 24 hours after becoming aware of the sae  hiruz ctu will submit to the central ec this study will be registered at clinicalstudies.gov, and results information from this study will be submitted to clinicalstudies.gov. in addition, every attempt will be made to publish results in peerreviewed journals. appendices appendix 1: uspi (us package insert) key: cord-029112-u507i0t0 authors: smith, keisha; pace, amy; ortiz, stephan; kazani, shamsah; rottinghaus, scott title: a phase 3 open-label, randomized, controlled study to evaluate the efficacy and safety of intravenously administered ravulizumab compared with best supportive care in patients with covid-19 severe pneumonia, acute lung injury, or acute respiratory distress syndrome: a structured summary of a study protocol for a randomised controlled trial date: 2020-07-13 journal: trials doi: 10.1186/s13063-020-04548-z sha: doc_id: 29112 cord_uid: u507i0t0 objectives: primary objective • to evaluate the effect of ravulizumab, a long-acting complement (c5) inhibitor plus best supportive care (bsc) compared with bsc alone on the survival of patients with covid-19. secondary objectives • number of days free of mechanical ventilation at day 29 • duration of intensive care unit stay at day 29 • change from baseline in sequential organ failure assessment (sofa) score at day 29 • change from baseline in peripheral capillary oxygen saturation/ fraction of inspired oxygen (spo2 /fio2) at day 29 • duration of hospitalization at day 29 • survival (based on all-cause mortality) at day 60 and day 90 safety • incidence of treatment-emergent adverse events and treatment-emergent serious adverse events. pk/pd/immunogenicity • change in serum ravulizumab concentrations over time • change in serum free and total c5 concentrations over time • incidence and titer of anti-alxn1210 antibodies biomarkers • change in absolute level of soluble biomarkers in blood associated with complement activation, inflammatory processes, and hypercoagulable states over time exploratory • incidence of progression to renal failure requiring dialysis at day 29 • time to clinical improvement (based on a modified 6-point ordinal scale) over 29 days • sf-12 physical component summary (pcs) and mental component summary (mcs) scores at day 29 (or discharge), day 60, and day 90 • euroqol 5-dimension 5-level (eq-5d-5l) scores at day 29 (or discharge), day 60, and day 90 trial design: this is a multicenter phase 3, open-label, randomized, controlled, study. the study is being conducted in acute care hospital settings in the united states, united kingdom, spain, france, germany, and japan. participants: male or female patients at least 18 years of age, weighing ≥ 40 kg, admitted to a designated hospital facility for treatment will be screened for eligibility in this study. key inclusion criteria • confirmed diagnosis of sars-cov-2 infection (eg, via polymerase chain reaction [pcr] and/or antibody test) presenting as severe covid-19 requiring hospitalization • severe pneumonia, acute lung injury, or ards confirmed by computed tomography (ct) or x-ray at screening or within the 3 days prior to screening, as part of the patient’s routine clinical care • respiratory distress requiring mechanical ventilation, which can be either invasive (requiring endotracheal intubation) or non-invasive (with continuous positive airway pressure [cpap] or bilevel positive airway pressure [bipap]) key exclusion criteria • patient is not expected to survive for more than 24 hours • patient is on invasive mechanical ventilation with intubation for more than 48 hours prior to screening • severe pre-existing cardiac disease (ie, nyha class 3 or class 4, acute coronary syndrome, or persistent ventricular tachyarrhythmias) • patient has an unresolved neisseria meningitidis infection excluded medications and therapies • current treatment with a complement inhibitor • intravenous immunoglobulin (ivig) within 4 weeks prior to randomization on day 1 excluded prior/concurrent clinical study experience • treatment with investigational therapy in a clinical study within 30 days before randomization, or within 5 half-lives of that investigational therapy, whichever is greater • exceptions a. investigational therapies will be allowed if received as part of best supportive care through an expanded access protocol or emergency approval for the treatment of covid-19. b. investigational antiviral therapies (such as remdesivir) will be allowed even if received as part of a clinical study. intervention and comparator: the study consists of a screening period of up to 3 days, a primary evaluation period of 4 weeks, a final assessment at day 29, and a follow-up period of 8 weeks. for patients randomized to ravulizumab plus bsc, a weight-based dose of ravulizumab (≥40 to < 60 kg/2400 mg, 60 to < 100 kg/2700 mg, ≥ 100 kg/3000 mg) will be administered on day 1. on day 5 and day 10, additional doses of 600 mg (≥40 to <60 kg) or 900 mg (>60 kg) ravulizumab will be administered and on day 15 patients will receive 900 mg ravulizumab. there is no active or placebo comparator in this open-label clinical trial. the total duration of each patient’s participation is anticipated to be approximately 3 months. main outcomes: the primary efficacy outcome of this study is survival (based on all-cause mortality) at day 29. randomisation: patients will be randomized in a 2:1 ratio (ravulizumab plus bsc:bsc alone). randomization will be stratified by intubated or not intubated on day 1. computer-generated randomization lists will be prepared by a third party under the direction of the sponsor. investigators, or designees, will enrol patients and then obtain randomization codes using an interactive voice/web response system. the block size will be kept concealed so that investigators cannot select patients for a particular treatment assignment. blinding (masking): this is an open-label study. numbers to be randomised (sample size): approximately 270 patients will be randomly assigned in a 2:1 ratio to ravulizumab plus bsc (n=180) or bsc alone (n=90). trial status: protocol number: alxn1210-cov-305 original protocol: 09 apr 2020 protocol amendment 1 (global): 13 apr 2020 protocol amendment 2 (global): 17 apr 2020 protocol amendment 3 (global): 09 jun 2020 recruitment is currently ongoing. recruitment was initiated on 11 may 2020. we expect recruitment to be completed by 30 nov 2020. trial registration: clinicaltrials.gov: protocol registry number: nct04369469; first posted; 30 apr 2020 eu clinical trials register: eudract number: https://www.clinicaltrialsregister.eu/ctr-search/search?query=alxn1210-cov-305, start date: 07 may 2020 full protocol: the full redacted protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. overall rationale for the amendment: this global amendment was initiated to update the inclusion and exclusion criteria, study endpoints and objectives, and the schedule of activities. patient-reported outcomes (sf-12 and eq-5d-5l) were added and changes were also implemented to align content in section 9 (statistical considerations) with version 1and version 2 of the statistical analysis plan. this amendment is considered to be substantial based on the criteria set forth in article 10(a) of directive 2001/20/ec of the european parliament and the council of the european union. substantive changes are documented in the table below. alexion confidential description of change brief rationale 1.1 -synopsis, 3 -objectives and endpoints 8.3. 2 • reordered secondary endpoints the ordering of testing for the secondary endpoints has been changed to align with the order of interest from a clinical and patient perspective. this reordering reduces the risk of a type ii error if a more clinically important endpoint is set below another endpoint in the hierarchy for which the null hypothesis is not rejected. the secondary endpoint of survival at day 60 and day 90 has been removed from the testing procedure when all patients have completed the primary evaluation period, which is day 29, as sufficient information for this endpoint may not be available. table s1 and table 5 correction of a typographical error given the half-life of the molecule, these expanded windows allow the investigational site staff to collect protocol-specified laboratory samples within a reasonable timeframe. footnote #16: revised to indicate that biomarker samples will be collected for all patients; however, for patients randomized to the ravulizumab + bsc treatment group biomarker samples will be collected any time before the start of infusion for clarity 1.3 -schedule of activities footnote #19: added statement to indicate that medical history should include the date of first onset of signs and symptoms of sars-cov-2 infection. for clarity added a clarifying statement that the 3-day screening period is allowed to evaluate patients for eligibility. if the screening and day 1 visits are combined, the patient has to meet all inclusion/no exclusion criteria prior to randomization. to clarify that patients may be evaluated for eligibility at any time during the 3-day screening period. revised criterion #2 -confirmed diagnosis of sars-cov-2 infection can be via pcr and/or antibody test removed rituximab and mitoxantrone as prohibited medications (criteria 5b and 5c) these medications have been historically disallowed in the sponsor's neurology studies due to a potential drug-drug interaction that could lower rituximab levels, and due to a potential confounding effect for efficacy with mitoxantrone. however, there is a very low likelihood that patients with severe covid-19 will be receiving these therapies in an acute setting, and the potential interactions are less important in this acute setting. therefore, the sponsor has elected to remove these medications from the list of excluded concomitant medications. 5.2 -exclusion criteria 6.5.1 -disallowed medicine and therapy revised washout period for ivig (criterion 5d) for clarity revised criterion to indicate that 1) patients who receive medications as part of bsc at the hospital due to emergency authorization under a compassionate use or expanded access program and 2) patients who receive antivirals (such as remdesivir) as part of a clinical study are eligible for participation in the study (criterion 6) to allow for enrollment of patients who may receive antivirals as part of a clinical study and receive treatment with investigational therapies under a compassionate use (emergency approval) or expanded access program removed verbiage indicating female patients will be evaluated for breastfeeding status or pregnancy at day 1 (criterion 7). correction of a typographical error added criterion #9 -allows enrollment of patients not currently vaccinated against neisseria meningitidis but who will receive prophylactic antibiotic treatment for at least 8 months after last infusion of study drug or until at least 2 weeks after they receive vaccination against n. meningitidis • added statement that the assessment of pao2 is optional and that the spo2 will serve as the surrogate for respiratory status • spo2/fio2 and the associated cutoff values were added to table 7 • added footnote to table 7 to allow for an alternate assessment of the respiratory system to help inform sofa scoring and for clarity revised to indicate that body weight has to be measured, but should be estimated using best judgement if it cannot be measured. for clarity revised to indicate that non-protocol-specified laboratory results that are considered clinically significant are not required to be entered in the crf/ecrf; however, the investigator is still required to report (and record in the ae crf/ecrf) the laboratory abnormality if deemed clinically significant the study is being implemented in an acute inpatient setting and non-protocol-specified laboratory results may not be readily accessible to sponsor staff for verification. to assess the effect of c5 inhibition on systemic activation of complement, inflammation, and prothrombic activity in patients with covid-19 • change in absolute levels of soluble biomarkers in blood associated with complement activation, inflammatory processes, and hypercoagulable states over time exploratory to evaluate the effect of ravulizumab + bsc compared with bsc alone on progression to renal failure requiring dialysis in patients with covid-19 • incidence of progression to renal failure requiring dialysis at day 29 to evaluate the effect of ravulizumab + bsc compared with bsc alone on clinical improvement in patients with covid-19 • time to clinical improvement (based on a modified 6-category ordinal scale) over 29 days to evaluate the effect of ravulizumab + bsc compared with bsc alone on the health-related quality of life of patients with covid-19 • sf-12 pcs and mcs scores at day 29 (or discharge), day 60, and day 90 • eq-5d-5l scores at day 29 (or discharge), day 60, and day 90 baseline is defined as the last available assessment on or before day 1 for all patients. day 1 will be defined as the date of the first infusion of ravulizumab for patients randomized and dosed with ravulizumab and as the date of randomization for patients randomized but not dosed with ravulizumab. abbreviations: bsc = best supportive care; c5 = complement component 5; covid-19 = coronavirus disease 2019; eq-5d-5l = euroqol 5-dimension 5-level; fio2 = fraction of inspired oxygen; mcs = mental component summary; pcs = physical component summary; pd = pharmacodynamic; pk = pharmacokinetic; sf-12 = 12-item short form; sofa = sequential organ failure assessment; spo2 = peripheral capillary oxygen saturation; teae = treatment-emergent adverse event; tesae = treatment-emergent serious adverse event. study alxn1210-cov-305 is a multicenter phase 3, open-label, randomized, controlled study designed to evaluate the safety and efficacy of intravenous (iv) ravulizumab + best supportive care (bsc), compared with bsc alone in patients with a confirmed diagnosis of sars-cov-2 infection, and a clinical presentation consistent with covid-19 severe pneumonia, acute lung injury, or ards. patients at least 18 years of age, weighing ≥ 40 kg, and admitted to a designated hospital facility for treatment will be screened for eligibility in this study. accounting for a 10% nonevaluable rate, approximately 270 patients will be randomized in a 2:1 ratio (180 patients to receive ravulizumab + bsc, 90 patients to bsc alone). patients randomized to ravulizumab + bsc will receive a weight-based dose of ravulizumab on day 1 (table s1 ). on day 5 and day 10, doses of 600 mg or 900 mg ravulizumab will be administered (according to weight category) and on day 15 patients will receive 900 mg ravulizumab. patients in both treatment groups will continue to receive medications, therapies, and interventions per standard hospital treatment protocols for the duration of the study. screening and the day 1 visits can occur on the same day if the patient has met all inclusion and no exclusion criteria. protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 this is an open-label parallel-treatment study. approximately 270 patients (180 ravulizumab + bsc, 90 bsc alone) will be randomly assigned to 1 of 2 treatment groups. the study consists of a screening period of up to 3 days, a primary evaluation period of 4 weeks, a final assessment at day 29, and a follow-up period of 8 weeks. the 2 follow-up visits will be conducted 4 weeks apart as a telephone call if the patient is discharged from the hospital or an in-person visit if the patient is still hospitalized. the total duration of each patient's participation is anticipated to be approximately 3 months. the dosage regimen to be administered during this study is provided in table s1 . no additional doses are allowed during the primary evaluation period (ie, from day 1 to day 29). a weight-based dose of ravulizumab will be administered on day 1 as follows: patients weighing ≥ 40 to < 60 kg: 2400 mg; ≥ 60 to < 100 kg: 2700 mg; or ≥ 100 kg: 3000 mg. a weight-based dose of ravulizumab will be administered on day 5 and day 10 as follows: patients weighing ≥ 40 to < 60 kg: 600 mg; ≥ 60 to < 100 kg: 900 mg; or ≥ 100 kg: 900 mg. on day 15, patients will receive 900 mg ravulizumab. **day 29 represents the end of the primary evaluation period. abbreviations: bsc = best supportive care; d = day; eos = end-of-study; n = number of patients. protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 page 22 of 86 alexion confidential 11 x x x x x x x x adverse event review and evaluation x <<monitor continuously>> x review safety card 12 x 12 x 12 x 12 x 12 safety laboratory tests (predose) 13 clinical chemistry x x x x x x x x hematology x x x x x x x x coagulation panel and d-dimer x x x x x x x x urinalysis x x x x x x x x direct coombs test x pk/pd/immunogenicity tests pk 14 x x x x x x x total and free c5 15 x x x x x x x immunogenicity (predose) 14 x x x biomarker tests serum and plasma biomarkers (predose) 16 x x x x x x x x other concomitant medication 17 x <<monitor continuously>> x nonpharmacologic treatments and therapies 18 x <<monitor continuously>> x patient-reported outcomes sf-12 x x eq-5d-5l x x protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 page 24 of 86 alexion confidential 6. confirmation of meningococcal vaccination within the past 5 years prior to dosing for patients randomized to ravulizumab + bsc. if vaccination cannot be confirmed, the patient should receive prophylactic antibiotics prior to initiating ravulizumab treatment and for at least 8 months from the last infusion of ravulizumab. when patients are vaccinated less than 2 weeks prior to treatment with ravulizumab or after initiation of ravulizumab, they should continue antibiotic prophylaxis for at least 2 weeks after meningococcal vaccination. 7. can be performed within the 3 days prior to screening or at screening. imaging performed as part of the patient's routine clinical care is expected and acceptable for inclusion in this study. 8. urine or serum pregnancy tests (beta human chorionic gonadotropin) to be performed in all female patients. a negative pregnancy test result is required before administration of ravulizumab. 9. spo2 to be measured by pulse oximetry. pao2 to be measured by arterial blood gas, if available. fio2 to be measured by supplemental oxygen. for patients treated with ravulizumab, spo2, pao2 (if available), and fio2 should be measured predose on day 1. the highest daily measurement of oxygen pressure or saturation on the lowest inspired supplemental oxygen level will be recorded in the crf/ecrf. complete or abbreviated physical examination is to be performed at the timepoints indicated in the soa. a complete physical examination will include, at a minimum, assessments of the following organs/body systems: skin, head, ears, eyes, nose, throat, neck, lymph nodes, chest, heart, abdomen, extremities, and musculoskeletal. an abbreviated physical examination consists of at least an evaluation of the respiratory and cardiovascular systems. clinically significant abnormalities or findings will be recorded in the ae crf/ecrf. vital sign measurements should include systolic and diastolic bp (millimeters of mercury [mm hg]), heart rate (beats/minute), respiratory rate (breaths/minute), and temperature (degrees celsius [°c] or degrees fahrenheit [°f]). these measurements will be taken predose on dosing days. when the patient is responsive and capable of understanding, review the patient safety information card (including discussion of the risks of meningococcal infections) during the hospitalization and at discharge. upon discharge, patients who received ravulizumab, must carry the patient safety information card at all times and for at least 8 months after the last infusion of ravulizumab. clinical safety laboratory measurements will be collected predose on dosing days. 14. serum samples for pk and immunogenicity analyses will be collected at the timepoints indicated in the soa for patients randomized to ravulizumab + bsc. on day 1/dosing days, immunogenicity and pk samples will be collected within 4 hours before the administration of ravulizumab (predose) and pk samples will be collected within 4 hours after the end-of-infusion (postdose). postdose pk samples must be collected from a separate line or needle stick to the noninfused arm, not from the infusion line. pharmacokinetic and immunogenicity samples can be collected at any time on nondosing days during the primary evaluation period. serum samples for total and free c5 analyses will be collected at the timepoints indicated in the soa for all patients. for patients randomized to ravulizumab + bsc, samples will be collected within 4 hours before the administration of ravulizumab (predose) and within 4 hours after the end-of-infusion (postdose) on dosing days. postdose samples must be collected from a separate line or needle stick to the noninfused arm, not from the infusion line. samples can be collected at any time on nondosing days during the primary evaluation period. serum and plasma biomarker samples for biomarker analyses will be collected for all patients at the timepoints indicated in the soa and stored at the investigational site prior to analysis by alexion or designee. samples will be collected predose (any time before infusion start) for patients who are randomized to the ravulizumab + bsc treatment group. concomitant medications and nonpharmacologic therapies considered relevant to the treatment of covid-19 (bsc) or ravulizumab treatment (eg, antimicrobials, antimalarials, antivirals, steroids, and vasopressors) that the patient is receiving, at the time of screening and for treating teaes/tesaes, will be recorded in the ae crf/ecrf. will be assessed via a telephone call at day 29 for all patients who are discharged before the end of the primary evaluation period (day 29). page 25 of 86 alexion confidential fio2 = fraction of inspired oxygen; na = not applicable; pao2 = partial pressure of oxygen; pd = pharmacodynamics; pk = pharmacokinetics; sars-cov-2 = severe acute respiratory syndrome coronavirus-2; sf-12 = 12-item short form; soa = schedule of activities; spo2 = peripheral capillary oxygen saturation; tesae = treatment emergent serious adverse event. protocol amendment 3 (global) the novel sars-cov-2 is a beta-coronavirus identified as the causative agent in covid-19 (cdc, covid 19 situation summary). clinical manifestations of covid-19 range from mild flu-like symptoms (eg, low grade fever, cough, fatigue) to ards, respiratory failure, multiple organ failure, and eventual death. an accelerating incidence of sars-cov-2 infections have been reported for patients who present with severe pneumonia, acute lung injury, or ards. emerging epidemiologic data indicate that approximately 30 -50% of patients with covid-19 may require hospitalization, approximately 10% may be admitted to critical care units, and 2.5% or more may die of multiorgan failure, especially those individuals who are older or have other comorbidities. for hospitalized patients, the world health organization (who) has issued recommendations on disease management and therapeutic regimens (who, 2020). aside from supportive care, no therapeutic regimens have been proven effective in reducing either the human-to-human transmission of the infection or its associated fatalities. mortality in those with critical illness has been reported as > 50%; therefore, implementation of proven critical care interventions such as lung protective ventilation is recommended by who. acute respiratory distress syndrome is a constellation of immune-mediated pathologies that are observed in severe cases of coronavirus infection (hammerschmidt, 1980) . this pattern was observed in 2002 with the emergence of severe acute respiratory syndrome-coronavirus (sars-cov), and in 2012 when a related coronavirus, middle east respiratory syndrome coronavirus (mers-cov) was identified (rota, 2003 , zaki, 2012 . complement activation and complement component 5a (c5a; the proinflammatory anaphylatoxin) are involved in multiple mechanisms in the development of acute lung disease induced by pathogenic viruses (wang, 2015) . emerging evidence suggests that activation of the complement system is involved in the pathogenesis of coronavirus (cov)-related ards, and that a c5 inhibitor may be an effective therapeutic in cov-mediated disease (gralinski, 2018 ). the complement system is a part of the immune system that enhances the ability of antibodies and phagocytic cells to clear pathogens and damaged cells. it is made up of more than 30 plasma protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 proteins that opsonize pathogens and induce a series of inflammatory responses to help fight infection. the complement system has key roles in innate and adaptive immune responses, but when hyperactivated can lead to tissue injury. within the complement system there are 3 pathways (classical, lectin, and alternative) that lead to cleavage of c5 and formation of the membrane attack complex, or terminal complement pathway. preclinical data have demonstrated a role for complement activation in cov-mediated disease. gralinski evaluated activation of the complement system in a mouse model of cov. the c57bl/6j mice were infected with mouse-adapted sars-cov which resulted in high-titer virus replication within the lung, induction of inflammatory cytokines and chemokines, and immune cell infiltration within the lung. complement activation was measured by detection of complement pathway component cleavage products. complement protein 3 activation products were detected in sars-cov ma15-infected mice, but not in control mice, as early as 1 day post-infection. complement protein 3 deposition was observed in the lungs of infected wildtype mice on day 2 and day 4 post-infection. transgenic animals lacking complement component 3 (c3) were protected from sars-cov-induced weight loss, had reduced pathology (inflammatory cells in the large airway and parenchyma, perivascular cuffing, thickening of the interstitial membrane, and low levels of intra-alveolar edema), had improved respiratory function, and exhibited lower levels of inflammatory cytokines or chemokines in the lung and periphery. notably, the kinetics of viral replication were unaltered in the c3-deficient mice relative to wildtype controls, suggesting that the observed effects were due to control of complement-mediated inflammatory processes and not reduction of viral titer. complement protein 3 is a central hub in the complement cascade and acts as a relay for activation from the alternative pathway. however transgenic mice lacking alternative pathway proteins factor b or c4 did not have the same protection from cov-mediated weight loss as compared with c3-deficient mice, suggesting that inhibition of the complement alternative pathway alone is insufficient. this implies that inhibition of a key relay point such as c3 or potentially c5, may be required. a second model of viral-mediated lung infection also points to a role for complement (jiang, 2018) . a mers-cov infection in mice causes severe acute respiratory failure and high mortality accompanied by elevated secretion of cytokines and chemokines. in these infected mice, excessive complement activation was detected. increased concentrations of c5a and terminal complement complex (c5b-9), activation products resulting from cleavage of c5, were detected in sera and lung tissue, respectively. blocking c5a with a specific antibody to the c5a receptor (c5ar) reduced alveolar macrophage infiltration and interferon (ifn)-gamma receptor expression in lung, resulting in less tissue damage. decreased spleen tissue damage was also observed. interestingly, anti-c5ar treatment led to decreased viral replication in lung tissues. patients infected by avian influenza virus h5n1 can also present with severe pneumonia, acute lung injury, or ards. the histopathological changes in the lungs are like those observed in severe acute respiratory syndrome (sars) (ng, 2006) . in a mouse model of h5n1, complement activates immune effector cells and drives lung inflammation. complement proteins c3a and c5a can increase vascular permeability, recruit and activate leukocytes, activate endothelial cells, upregulate adhesion molecule and cytokine expression, and induce goblet cell secretion of mucus, exacerbating disease through multiple mechanisms. in these mice, deposition of c3, c5b-9, and mannose-binding lectin (mbl)-c was observed in lung tissue. upregulation of mbl-associated serine protease-2 (masp-2) and complement receptors c3ar and c5ar was also detected. specific inhibition of either c3ar or c5a in the infected mice was effective in reducing lung damage, attenuating inflammation and neutrophil infiltration in the lung, and improving survival (sun, 2013 ). clinical evidence suggests that complement is activated during sars infection and that the progression of severe pneumonia, acute lung injury, or ards in these patients is strongly associated with complement activation. the c3c fragment is present in the sera of patients with sars and is a strong indicator of disease severity (pang, 2006) . consistent with this finding, the complement activation product c5a is associated with the inflammatory response and severe lung damage that occurs in patients infected with the 2009 h1n1 influenza virus (ohta, 2011) . it has also been shown that sars-cov can directly activate complement via the lectin pathway (ip, 2005) . patients with sars develop autoantibodies against human epithelial cells and endothelial cells that mediate complement-dependent cytotoxicity (yang, 2005) . multiple lines of evidence support the hypothesis that complement is a key mediator of virally-induced lung damage and that acute lung injury associated with cov infection is partially mediated by complement (wong, 2004) . therefore, it is plausible to hypothesize that covid-19-related injuries and multiorgan failures are mediated, at least in part, by complement activation. the existing data point to the role of c3 and the terminal complement complex, but not the alternative pathway alone. inhibition of complement, specifically at the terminal complement node through inhibition of c5, may control the inflammatory processes which drive ards. at present, there are no therapies that have received global approval by regulatory authorities for the prevention and/or treatment of covid-19. china's national health commission recently updated treatment guidelines for covid-19 recommending the use of tocilizumab (anti-interleukin [il] 6r monoclonal antibody [mab]) to treat chinese patients infected with sars-cov-2 who have developed serious lung damage and have elevated levels of il-6 in the blood. a variety of supportive therapies are being used in an attempt to improve prognosis in critically ill patients with confirmed covid-19 presenting with severe pneumonia, acute lung injury, or potentially life-threatening ards. despite the use of these supportive agents, patients have continued to experience deterioration of respiratory function, a critical contributor to fatal outcomes. ravulizumab is a mab that specifically binds to the complement protein c5 with high affinity, thereby inhibiting its cleavage to c5a and c5b (the initiating subunit of c5b-9) and preventing the generation of the terminal complement complex c5b-9. this mechanism of action provides a therapeutic rationale for the use of ravulizumab in diseases in which complement activation is involved. in addition, the selective blockade of complement cascade at c5 by ravulizumab preserves the activity of upstream components of the complement cascade that are known to be essential for opsonization of microorganisms and prevention of immune complex disorders (prodinger, 1999) . importantly, c5 blockade preserves the immunoprotective and immunoregulatory functions of early complement components. complement inhibition has been shown to be an effective therapeutic target in hematological and neuroinflammatory diseases. ravulizumab is proposed for the treatment of patients with confirmed sars-cov-2 infection with a clinical presentation consistent with covid-19 severe protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 pneumonia, acute lung injury, or ards. treatment with ravulizumab produces complete and sustained inhibition of c5-mediated terminal complement activity. treatment with ravulizumab could improve outcomes in patients with covid-19 severe pneumonia, acute lung injury, or ards. benefit/risk assessment 2.3.1. potential risks associated with participation in this study and risk mitigation measures are enumerated in table 2 . if vaccination cannot be confirmed, the patient should receive prophylactic antibiotics against meningococcal infection prior to initiating ravulizumab treatment and for at least 8 months from the final infusion of ravulizumab (only applicable to patients exposed to study drug). when patients are vaccinated less than 2 weeks prior to treatment with ravulizumab or after initiation of ravulizumab, they should continue antibiotic prophylaxis for at least 2 weeks after meningococcal vaccination. ravulizumab could increase the risk of infection in this patient population. this potential risk is based on the mode of action of ravulizumab and experience with the use of eculizumab. since the relevance of serious infection with ravulizumab therapy has not been confirmed in clinical studies, this remains a potential risk. training healthcare professionals and patients about the potential risk of additional serious infection. monitoring for signs and symptoms of serious infections will be conducted as part of routine safety assessments for this study. in addition to appropriate antibiotic coverage versus infection and opportunistic infections, guidelines for immune reconstitution and revaccination will be followed, as applicable. immunogenicity treatment with any therapeutic protein has the potential to induce an immune response. potential clinical consequences may include severe hypersensitivity type reactions, across 350 patients enrolled in ravulizumab, phase 3 clinical studies, 2 patients were reported with treatment-emergent adas. protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 page 30 of 86 alexion confidential decrease in efficacy and induction of autoimmunity, including antibodies to the endogenous form of the protein (li, 2002; casadevall, 2002) . presence of anti-alxn1210 antibodies will be assessed. protein therapies administered intravenously have the potential risk of causing local (infusion-site) reactions and systemic reactions (infusion-associated reactions). monitoring for infusion reactions will be conducted as part of routine safety assessments for this study. management of potential infusion reactions is detailed in section 10.6. no studies of ravulizumab have been conducted in pregnant women. there are no data available on excretion of ravulizumab in breast milk. pregnant or nursing female patients will be excluded from participating in this clinical study. patients and their spouses/partners must use a highly effective or acceptable method of contraception for a period of 8 months following the final infusion of ravulizumab. breastfeeding should be discontinued during treatment and up to 8 months after the final infusion of ravulizumab. abbreviations: ada = antidrug antibody. potential benefits of study participation include: • improve survival rate of patients with sars-cov-2 infection who are receiving ravulizumab + best supportive care (bsc) compared with bsc alone • decrease lung injury in patients with sars-cov-2 infection while on supportive medical care • improve clinical outcomes in patients with sars-cov-2 infection while on supportive medical care although the efficacy of ravulizumab has not been previously studied in patients with severe pneumonia, acute lung injury, or ards, the emerging evidence for the scientific rationale, the predicted drug concentrations and pharmacodynamic (pd) effects after administration of the recommended dose (section 4.3), and its established safety profile indicate that ravulizumab is an appropriate candidate for clinical investigation, and that the potential for clinical benefit outweighs the risk of treatment with ravulizumab for patients participating in study alxn1210-cov-305. the safety profile of ravulizumab is well characterized in the current clinical development programs, including approved indications in paroxysmal nocturnal hemoglobinuria (pnh) and protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 page 31 of 86 alexion confidential atypical hemolytic uremic syndrome (ahus). known and potential risks can be effectively managed with the risk mitigation strategies currently in place for ravulizumab. more detailed information about the known and expected benefits and risks and reasonably expected adverse events (aes) of ravulizumab may be found in the investigator's brochure (ib). to characterize the pk/pd and immunogenicity of ravulizumab in patients with covid-19 • change in serum ravulizumab concentrations over time • change in serum free and total c5 concentrations over time • incidence and titer of anti-alxn1210 antibodies biomarkers to assess the effect of c5 inhibition on systemic activation of complement, inflammation, and prothrombic activity in patients with covid-19 • change in absolute levels of soluble biomarkers in blood associated with complement activation, inflammatory processes, and hypercoagulable states over time exploratory to evaluate the effect of ravulizumab + bsc compared with bsc alone on progression to renal failure requiring dialysis in patients with covid-19 • incidence of progression to renal failure requiring dialysis at day 29 to evaluate the effect of ravulizumab + bsc compared with bsc alone on clinical improvement in patients with covid-19 • time to clinical improvement (based on a modified 6-point ordinal scale) over 29 days to evaluate the effect of ravulizumab + bsc compared with bsc alone on the health-related quality of life of patients with covid-19 • sf-12 pcs and mcs scores at day 29 (or discharge), day 60, and day 90 • eq-5d-5l scores at day 29 (or discharge), day 60, and day 90 baseline is defined as the last available assessment on or before day 1 for all patients. day 1 will be defined as the date of the first infusion of ravulizumab for patients randomized and dosed with ravulizumab and as the date of randomization for patients randomized but not dosed with ravulizumab. study alxn1210-cov-305 is a multicenter phase 3, open-label, randomized, controlled study designed to evaluate the safety and efficacy of intravenous (iv) ravulizumab + bsc, compared with bsc alone, in patients with a confirmed diagnosis of sars-cov-2 infection, and a clinical presentation consistent with covid-19 severe pneumonia, acute lung injury, or ards. patients at least 18 years of age, weighing ≥ 40 kg, and admitted to a designated hospital facility for treatment will be screened for eligibility in this study. accounting for a 10% nonevaluable rate, approximately 270 patients will be randomized in a 2:1 ratio (180 patients to receive ravulizumab + bsc, 90 patients to receive bsc alone). patients randomized to ravulizumab + bsc will receive a weight-based dose of ravulizumab on day 1 (table s1 ). on day 5 and day 10, doses of 600 mg or 900 mg ravulizumab will be administered (according to weight category) and on day 15 patients will receive 900 mg ravulizumab. patients in both treatment groups will continue to receive medications, therapies, and interventions per standard hospital treatment protocols for the duration of the study. the study consists of a screening period of up to 3 days, a primary evaluation period of 4 weeks, a final assessment at day 29, and a follow-up period of 8 weeks. the 2 follow-up visits will be conducted 4 weeks apart as a telephone call if the patient is discharged from the hospital or an in-person visit if the patient is still hospitalized. the total duration of each patient's participation is anticipated to be approximately 3 months (figure 1 ). screening and the day 1 visits can occur on the same day if the patient has met all inclusion and no exclusion criteria. this is an open-label, 2:1 randomized, controlled study. o a randomized, controlled study design minimizes bias to selection or treatment allocation. this design will ensure identification of an effective treatment that may improve survival in patients with covid-19 severe pneumonia, acute lung injury, or ards. o the 2:1 randomization will ensure that approximately two-thirds of patients are exposed to treatment and provides more safety information in this patient population for benefit-risk assessment. study alxn1210-cov-305 is being conducted in patients with sars-cov-2 infection with a clinical presentation consistent with covid-19 severe pneumonia, acute lung injury, or ards. o there is no approved treatment for patients with the severe form of covid-19. o clinical evidence suggests that complement is activated during sars infection and that the progression of disease is also associated with complement activation. protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 page 34 of 86 alexion confidential o treatment with ravulizumab could 1) decrease lung injury and improve clinical outcomes in patients with sars-cov-2 infection while on supportive medical care and 2) provide additional time for patients to recover. for patients randomized to ravulizumab + bsc, a weight-based dose of ravulizumab will be administered on day 1. on day 5 and day 10, additional doses of 600 mg or 900 mg ravulizumab will be administered (according to weight category) and on day 15 patients will receive 900 mg ravulizumab. o preliminary pk/pd data suggest that the complement system is amplified in patients with covid-19 severe pneumonia, acute lung injury, or ards beyond what has been observed in patients with ahus and that additional doses of ravulizumab are needed to provide complete and sustained complement inhibition. o due to the rapid activation of complement associated with the severe form of covid-19 (ie, hyperinflammatory response known as cytokine storm syndrome [mehta, 2020] ), this ravulizumab dosage regimen is expected to improve survival and clinically relevant endpoints in these patients. o the chosen primary endpoint is anticipated to reflect a ravulizumab treatment effect over 4 weeks and thus an immediate impact on survival. secondary endpoints o most secondary endpoints were selected based on society of critical care medicine recommendations for standardized endpoints in clinical studies using an intervention to reduce the duration of mechanical ventilation (blackwood, 2019) . o the sofa score is a validated endpoint used in the critical care setting to determine clinical outcomes (eg, multiorgan failure) (lambden, 2019) . this is the basis of the therapeutic strategy to achieve complete complement inhibition in patients with covid-19 infection who present with severe pneumonia, acute lung injury, and/or ards. the end of the primary evaluation period is defined as the date when the last surviving patient completes the day 29/early termination (et) visit. the end of the study is defined as the last patient's last visit, which may be the final safety follow-up telephone call or in-person visit. prospective approval of protocol deviations to recruitment and enrollment criteria, also known as protocol waivers or exemptions, are not permitted. the sponsor allows a 3-day screening period to evaluate patients for eligibility. if the screening and day 1 visits are combined, the patient must meet all inclusion criteria and not meet any exclusion criteria prior to randomization. patients are eligible to be included in the study only if all the following criteria apply: age 1. patient must be ≥ 18 years of age at the time of providing informed consent. 7. female patients of childbearing potential and male patients with female partners of childbearing potential must follow protocol-specified contraception guidance for avoiding pregnancy for 8 months after treatment with the study drug (as described in section 10.4 [appendix 4]). patients are excluded from the study if any of the following criteria apply: 1. patient is not expected to survive for more than 24 hours. 2. patient is on invasive mechanical ventilation with intubation for more than 48 hours prior to screening. a. current treatment with a complement inhibitor or b. intravenous immunoglobulin (ivig) within 4 weeks prior to randomization on day 1. 6. treatment with investigational therapy in a clinical study within 30 days before randomization, or within 5 half-lives of that investigational therapy, whichever is greater exceptions: a. investigational therapies will be allowed if received as part of best supportive care through an expanded access protocol or emergency approval for the treatment of covid-19. b. investigational antiviral therapies (such as remdesivir) will be allowed even if received as part of a clinical study. 7. female patients who are breastfeeding or who have a positive pregnancy test result at screening. 8. history of hypersensitivity to any ingredient contained in the study drug, including hypersensitivity to murine proteins. 9. patient who is not currently vaccinated against n. meningitidis, unless the patient agrees to receive prophylactic treatment with appropriate antibiotics for at least 8 months after the last infusion of study drug or until at least 2 weeks after the patient receives vaccination against n. meningitidis. no lifestyle considerations are applicable for this study. screen failures are defined as patients who provide informed consent, did not meet any inclusion/exclusion criteria, and are not randomly assigned to treatment. a minimal set of screen failure information is required to ensure transparent reporting of screen failure patients to meet the consolidated standards of reporting trials (consort) publishing requirements. minimal information includes demography (if allowable per local regulations), screen failure details (eg, failed eligibility criteria), and any aes, including any serious adverse events (saes) and any relevant concomitant medication use during the screening period. individuals who do not meet the criteria for participation in this study (screen failure) due to a reason that is expected to resolve or has resolved may be rescreened based on discussion and agreement between the investigator and the medical monitor. ravulizumab, a recombinant humanized anti-c5 mab composed of two 448 amino acid heavy chains and two 214 amino acid light chains, is an igg2/4 kappa immunoglobulin consisting of human constant regions, and murine complementarity-determining regions grafted onto human framework light-and heavy-chain variable regions. ravulizumab is produced in chinese hamster ovarian cell lines and was designed through minimal targeted engineering of eculizumab by introducing 4 unique amino acid substitutions to its heavy chain to extend antibody half-life. ravulizumab drug product is supplied for clinical studies as a sterile, preservative-free 10 mg/ml solution in single-use vials and designed for infusion by diluting into commercially available saline (0.9% sodium chloride injection; country-specific pharmacopeia) for administration via iv infusion. the proposed dosage regimen for the treatment of patients with covid-19 who are ≥ 18 years and ≥ 40 kg and are randomized to ravulizumab + bsc is presented in table 5 . the patient's body weight will be recorded on the day of the infusion visit. if the weight at the day of the infusion cannot be obtained, the weight recorded during the previous study visit may be used. abbreviations: covid-19 = coronavirus disease 2019. ravulizumab drug product is formulated at ph 7.0 and each 30 ml vial contains 300 mg of ravulizumab, 0.02% polysorbate 80, 150 mm sodium chloride, 6.63 mm sodium phosphate dibasic, 3.34 mm sodium phosphate monobasic, and water for injection, united states pharmacopeia. the ravulizumab admixture will be administered to the patient using an iv tubing set via an infusion pump followed by an iv flush. use of a 0.2 micron filter is required during the infusion. the iv flush is infused at the same rate of the infusion and end of flush is considered the end of infusion. the iv flush volume is not to be included in the total volume of study drug administered. additional details are provided in the pharmacy manual. ravulizumab will be manufactured and supplied by alexion in single 30 ml vials as a solution concentration of 10 mg/ml (table 6 ). each vial contains 300 mg of ravulizumab for iv administration. protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 stability studies of the diluted admixture of ravulizumab (10 mg/ml) in 0.9% sodium chloride injection support an in-use stability of 6 hours at room temperature at 23°c -27°c (73°f -80°f) and 24 hours when refrigerated at 2°c -8°c (36°f -46°f). ravulizumab vials should not be frozen or shaken. the investigator or designee must confirm appropriate temperature conditions have been maintained during transit for all study intervention received and any discrepancies are reported and resolved before use of the study intervention. only patients enrolled in the study and randomized to the ravulizumab + bsc group may receive the study intervention and only authorized site staff may supply or administer the study intervention. all study intervention must be stored in a secure, environmentally controlled, and monitored (manual or automated) area in accordance with the labeled storage conditions with access limited to the investigator and authorized site staff. the investigator, institution, or the head of the medical institution (where applicable) is responsible for study intervention accountability, reconciliation, and record maintenance (ie, receipt, reconciliation, and final disposition records). this responsibility includes the reporting of any product complaints* to within 1 business day of awareness. *a product complaint is defined as any written, electronic, or oral communication that alleges deficiencies related to the identity, quality, durability, reliability, usability, safety, effectiveness, or performance of a product or clinical study material and/or its packaging components after it is has been released for distribution to an end customer that affects the performance of such product. further guidance and information are provided in the pharmacy manual. alxn1210-cov-305 09 jun 2020 this is an open-label study. eligible patients who meet all inclusion and no exclusion criteria will be randomized in a 2:1 ratio to receive either ravulizumab + bsc or bsc alone. randomization will be stratified by intubated or not intubated on day 1. a randomization schedule will be developed by a centralized third party. when patients are dosed at the investigational site, they will receive ravulizumab directly from the investigator or designee, under medical supervision, thereby minimizing noncompliance. the date and time of the dose administered will be recorded in the source documents and recorded in the case report form (crf)/electronic case report form (ecrf). the dose of ravulizumab and study patient identification will be confirmed at the time of dosing by a member of the investigational site staff. patients may receive appropriate concomitant medications, including antivirals, as part of bsc during this clinical study, unless prohibited per exclusion criterion 5. concomitant medications considered relevant to treatment of covid-19 or ravulizumab treatment (eg, vaccines, antimicrobials, antimalarials, antivirals, steroids, and vasopressors) that the patient is receiving at the time of enrollment or receives during the study must be recorded in the crf/ecrf along with: • reason for use, • dates of administration, including start and end dates, and • dosage information including dose and frequency. the medical monitor should be contacted if there are any questions regarding concomitant therapy. use of the following medications and therapies is prohibited for the specified duration prior to screening and for the duration of the study: • current treatment with a complement inhibitor, and • intravenous immunoglobulin (ivig) within 4 weeks prior to randomization on day 1. additional doses are not allowed during the study. the dosage regimen to be administered during this study is provided in table 5 . patients will continue to be under the care of their treating physician after the study has concluded. this is an open-label study. study drug discontinuation is only applicable for patients who are randomized to ravulizumab + bsc. in rare instances, it may be necessary for a patient to permanently discontinue (definitive discontinuation) the study drug. if the study drug is definitively discontinued, the patient should remain in the study to be evaluated for safety. patients should be considered for discontinuation from study drug if any of the following occur: • serious hypersensitivity reaction; • severe uncontrolled infection; • use of disallowed medication as defined in section 6.5; • pregnancy or planned pregnancy; or • alexion or the investigator deems it is necessary for the participant. data to be collected at the time of discontinuation of study drug, including follow-up for any further evaluations that need to be completed is provided in the schedule of activities (soa , table 1 ). • when applicable, all efforts should be made to ensure patients are willing to comply with study participation prior to conducting the screening procedures. the study staff should notify alexion and their site monitor of all study withdrawals as soon as possible. the reason for patient discontinuation must be recorded in the source documents and crf/ecrf. • a patient may withdraw from the study at any time at his/her own request or may be withdrawn at any time at the discretion of the investigator for safety, behavioral, compliance, or administrative reasons. this is expected to be uncommon. • at the time of discontinuing from the study, if possible, an et visit should be conducted. refer to the soa (table 1) for assessments to be collected at the time of study discontinuation and follow-up. • if the patient withdraws consent for disclosure of future information, alexion may retain and continue to use any data collected before such a withdrawal of consent. • if a patient withdraws from the study, he/she may request destruction of any samples taken and not tested, and the investigator must document this in the site study records. if a patient is unreachable for a scheduled visit within the acceptable visit window (soa , table 1 ), the site study staff must make a reasonable attempt to contact the patient to determine protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 page 45 of 86 alexion confidential the reason for missing the visit. if the patient continues to be unreachable, he/she will be considered as lost to follow-up. discontinuation of specific sites or of the study as a whole is handled as part of section 10.1.8. alxn1210-cov-305 09 jun 2020 page 46 of 86 alexion confidential • study procedures and their timing are summarized in the soa (table 1 ). the list of clinical laboratory tests to be performed is provided in section 10.2. • immediate safety concerns should be discussed with alexion immediately upon occurrence or awareness to determine if the patient should continue or discontinue study intervention. • adherence to the study design requirements, including those specified in the soa (table 1) , is essential and required for study conduct. • all screening evaluations must be completed and reviewed to confirm that potential patients meet all eligibility criteria. the investigator will maintain a screening log to record details of all patients screened and to confirm eligibility or record reasons for screening failure, as applicable. • procedures conducted as part of the patient's routine clinical management (eg, blood count) and obtained before signing of the informed consent form (icf) may be utilized for screening or baseline purposes provided the procedures met the protocol-specified criteria and were performed within the time frame defined in the soa (section 1.3). patients or their legally acceptable representative must be consented per the informed consent process outlined in section 10.1.3. if allowable per local regulations, exceptions may be granted in cases where the patient is unable to provide informed consent. all inclusion (section 5.1) and exclusion (section 5.2) criteria must be reviewed by the investigator or qualified designee to ensure the patient qualifies for study participation. the patient's relevant medical history, including prior and concomitant conditions/disorders, treatment history, and history of medical conditions (ie, cardiovascular and respiratory, including smoking status) will be evaluated by the investigator and documented in the source documents and crf/ecrf. medical history should also include date of first onset of signs and symptoms of sars-cov-2 infection. a review of demographic parameters, including age, gender, race, and ethnicity will be performed, if allowable per local regulations. protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 confirmation of meningococcal vaccination within the past 5 years prior to dosing for patients randomized to ravulizumab + bsc. if vaccination cannot be confirmed, the patient should receive prophylactic antibiotics prior to initiating ravulizumab treatment and for at least 8 months from the last infusion of ravulizumab. when patients are vaccinated less than 2 weeks prior to treatment with ravulizumab or after initiation of ravulizumab, they should continue antibiotic prophylaxis for at least 2 weeks after meningococcal vaccination. additional guidance is provided in section 8.4.9. the sars-cov-2 infection will be evaluated at the designated hospital. a confirmed positive result (eg, via pcr and/or antibody test) is required before randomization. chest ct or x-ray scans will be performed during the screening period to confirm findings consistent with severe pneumonia, acute lung injury, or ards in patients with covid-19. scans performed during the course of the patient's clinical care are accepted and expected to fulfil this diagnostic inclusion criterion for study alxn1210-cov-305. urine or serum pregnancy tests (beta human chorionic gonadotropin) will performed in all female patients. a negative pregnancy test result is required before administration of ravulizumab. survival at day 29 will be determined. the following secondary efficacy parameters will also be measured through day 29: • mechanical ventilation status, • time in the intensive care unit (icu), • sequential organ failure assessment (sofa) score, • oxygen saturation levels (peripheral capillary oxygen saturation [spo2]), • duration of hospitalization. the following secondary efficacy parameter will be measured at day 60 and day 90: protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 • survival (based on all-cause mortality) multiple organ failure is a significant indicator of mortality in patients admitted to the icu. in this study, patients will be evaluated using the sofa score, an assessment tool that includes a review of 6 organ systems: respiratory, renal, hepatic, cardiac, coagulation, and central nervous system (vincent, 1998) . each organ system is scored from 0 to 4 points using the worst value observed within the previous 24 hours (table 7) . arterial blood gas may not be drawn on a protocol-specified visit day; therefore, the assessment of partial pressure of oxygen (pao2) is optional and the highly correlated spo2 will be a surrogate for the respiratory system assessment. 13 -14 10 -12 6 -9 < 6 1. as arterial blood gas may not be drawn on a protocol-specified visit day, the pao2 assessment is optional. abbreviations: cns = central nervous system; gcs = glasgow coma scale; fio2 = fraction of inspired oxygen; pao2 = partial pressure of oxygen; spo2 = peripheral capillary oxygen saturation. source: vincent, 1998; pandharipande, 2006 8.4. safety assessments the following safety-related parameters will be measured through day 29. protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 • complete or abbreviated physical examinations will be assessed by the investigator or designee. a complete physical examination will include, at a minimum, assessments of the skin, head, ears, eyes, nose, throat, neck, lymph nodes, chest, heart, abdomen, extremities, and musculoskeletal. an abbreviated physical examination will include at a minimum, assessment of the respiratory system and cardiovascular systems. • body weight should be measured, but if the site does not have the capacity to measure the patient's body weight it should be estimated using best judgement. investigators or designees should pay special attention to clinical signs related to previous serious illnesses. clinically significant abnormalities or findings will be recorded on the ae crf/ecrf. vital sign measurements will include systolic and diastolic blood pressure (millimeters of mercury [mm hg]), heart rate (hr, beats/minute), respiratory rate (rr, breaths/minute), and temperature (degrees celsius [°c] or degrees fahrenheit [°f]). vital sign measurements will be taken predose on dosing days. • a single 12-lead electrocardiogram (ecg) will be conducted to obtain hr, pulse rate (pr) interval, combination of the q wave, r wave and s wave (qrs) interval, interval between the start of the q wave and the end of the t wave (qt), and the corrected qt (qtc) interval(s). • the investigator must review the laboratory report, document this review, and record any clinically relevant changes occurring during the study in the ae crf/ecrf. the laboratory reports must be filed with the source documents. clinically significant abnormal laboratory findings are those that are not associated with the underlying disease, unless judged by the investigator or designee to be more severe than expected for the patient's condition. • all laboratory tests with values considered clinically significantly abnormal during participation in the study should be repeated until the values return to normal or baseline or are no longer considered clinically significant by the investigator or the medical monitor. − if such values do not return to normal/baseline within a period of time judged reasonable by the investigator, the etiology should be identified, and alexion notified. − all protocol-required laboratory assessments, as defined in section 10.2, must be conducted in accordance with the laboratory manual and the soa (table 1) . − laboratory assessments performed at the institution's local laboratory that require a change in patient management or are considered clinically significant by the protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 investigator (eg, reported as an sae or ae), must be recorded in the ae crf/ecrf. details of immunogenicity assessments are presented in section 8.12. the glasgow coma scale (gcs) is a validated prognostic tool used in the clinical assessment of unconsciousness (eg, patients who are comatose) (sternbach, 2000) .the gcs is comprised of 3 domains -eye response, verbal response, and motor response and within each domain contains a subset of responses that are separately assigned a score ( table 8 ). the gcs has also been used in the critical care setting as an aid in managing respiratory support. a total gcs score of < 8 is indicative of a patient's need for endotracheal intubation. the gcs will be measured to enable calculation of the secondary efficacy endpoint, sofa score. • pregnancy data from all female patients and female spouses/partners of male patients will be collected from the signing of the icf until the conclusion of the study participation. if a pregnancy is reported, the investigator must immediately inform alexion within 24 hours of awareness of the pregnancy and follow the procedures outlined in section 10.4. • for all alexion products, both in development or post-approval, exposure during pregnancy must be recorded and the pregnancy followed, until the outcome of the pregnancy is known (ie, spontaneous miscarriage, elective termination, normal birth, or protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 congenital abnormality), even if the patient discontinues the study intervention or withdraws from the study. the corresponding infant must be followed-up with for 3 months postpartum. • pregnancy is not considered as an ae (section 10.4.3) unless there is a suspicion that ravulizumab may have interfered with the effectiveness of a contraceptive medication. however, complications of pregnancy and abnormal outcomes of pregnancy are aes and may meet the criteria for an sae (eg, ectopic pregnancy, spontaneous abortion, intrauterine fetal demise, neonatal death, or congenital anomaly) (section 8.6). elective abortions without complications should not be reported as aes. when patients randomized to ravulizumab + bsc are able to understand, a patient safety information card will be provided to carry with them at all times. the card is provided to increase patient awareness of the risk of meningococcal infections, and promote quick recognition and disclosure of any potential signs or symptoms of infection experienced during the course of the study and to inform patients on what actions must be taken if they are experiencing signs or symptoms of infection. at each visit throughout the study, the study staff will ensure that the patient has the patient safety information card. patients are required to carry the patient safety information card for 8 months after the last infusion of ravulizumab. it is anticipated that patients randomized to ravulizumab + bsc who have not received a meningococcal vaccination within the past 5 years may be unable to receive meningococcal vaccinations prior to initiating treatment with ravulizumab during this study. if vaccination cannot be confirmed, the patient should receive prophylactic antibiotics against meningococcal infection prior to initiating ravulizumab treatment and for at least 8 months from the last infusion of ravulizumab. when patients can be vaccinated, vaccines against meningococcal serotypes a, c, y, w135, and b, where available, are recommended to prevent common pathogenic meningococcal serotypes. patients must be vaccinated or revaccinated according to the current national vaccination guidelines or local practice for vaccination use with complement inhibitors (eg, ravulizumab). vaccination may not be sufficient to prevent meningococcal infection. consideration should be given per official guidance and local practice on the appropriate use of antibacterial agents. when patients are vaccinated after initiation of ravulizumab, they should continue antibiotic prophylaxis for at least 2 weeks after meningococcal vaccination. if a patient is discharged before the end of the primary evaluation period, the patient will be contacted via telephone on day 29 to assess health status (survival, mechanical ventilation, hospitalization, intensive care unit, and dialysis). alxn1210-cov-305 09 jun 2020 follow-up visits will be conducted as indicated in the soa (table 1) to review patient status; including survival, monitoring for pregnancy, and to obtain information about new or worsening treatment-emergent saes (tesaes). the follow-up visits will be conducted as a telephone call if the patient is discharged from the hospital or an in person visit if the patient is still hospitalized. if a patient is discontinued from the study during the primary evaluation period (ie, from day 1 through day 29), the patient should present for the early termination visit, to be conducted as specified in the soa (table 1) . the patient will be contacted via telephone on day 29 to assess health status (eg, survival, mechanical ventilation, hospitalization, intensive care unit, and dialysis). the following exploratory parameters will also be measured: • progression to renal failure requiring dialysis at day 29 a reduction in the time to clinical improvement, especially when the patient is treated within a short timeframe from symptom onset has been reported in studies comparing antivirals to placebo (wang, 2020) . time to clinical improvement will be evaluated during this study and is defined as a live discharge, a decrease from of least 2 points (ie, #5 to #3) from baseline, or both. a modified 6-category ordinal scale (itemized below) will be used to evaluated clinical improvement. the short-form (sf)-12 is a validated health-related quality of life (hr-qol) instrument that is widely used across a broad spectrum of disease indications. adapted from the 36 -item sf survey that was designed to evaluate physical and mental health status, the sf-12 survey contains only 12 questions but covers the same 8 domains. there is a further stratification into 2 summary measures (physical component summary and mental component summary ) as specified below. (2 items) the pcs-12 and mcs-12 summary measures are scored using a norm-based method (ie, mean = 50, sd = 10) (jenkinson, 1997) . a pcs-12 or mcs-12 score of 50 indicates an average score with respect to a healthy population. scores lower than 50 reflect less than average health and scores greater than 50 reflect better than average health (ware, 1995) . the sf-12 assumes a recall of 1 week before responding to questions. the survey is anticipated to be completed in several minutes and can be completed by the patient or via an interviewer (in-person or over the telephone). the euroqol 5-dimension, 5 severity level (eq-5d-5l) questionnaire is a brief, validated, hr-qol instrument that is intended to assess the patient's health status at the time of administration. the questionnaire contains 5 dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), each of which includes 5 response variables (no problems, slight problems, moderate problems, severe problems, and extreme problems) (eq -5d, 2019) there is no summary score generated upon completion, but rather a 5-digit profile (termed "health state") based on each of the dimensions that can be further converted to a single numerical score (index value).value sets (a collection of index values) have been derived for multiple countries/regions. a vertical visual analogue scale (vas) is included for patients to indicate a self-rated estimate of their health. the vas ranges from 100 (best health you can imagine) to 0 (worst health you can imagine). the eq-5d-5l questionnaire and vas are anticipated to be completed in several minutes and can be completed by the patient, via an interviewer (in-person or over the telephone); or via proxy. the definitions of aes and saes can be found in section 10.3. all aes will be reported to the investigator or qualified designee by the patient (or, when appropriate, by a caregiver, surrogate, or the patient's legally acceptable representative). protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 the investigator and any qualified designees are responsible for detecting, documenting, and recording events that meet the definition of an ae or sae and remain responsible for following up aes that are serious, considered related to the study intervention or study procedures, or that caused the patient to discontinue the study intervention (see section 7). procedures for recording, evaluating, follow-up, and reporting aes and saes are outlined in section 10.3 (appendix 3). all aes and saes will be collected from the time of informed consent until through the timepoints specified in the soa (table 1) . all saes will be recorded and reported to alexion or the designee immediately and under no circumstance should this exceed 24 hours, as indicated in section 10.3 (appendix 3). the investigator will submit any updated sae data to alexion within 24 hours of it being available. investigators are not obligated to actively seek ae or sae data after conclusion of the study participation. however, if the investigator learns of any sae, including a death, at any time after a patient has been discharged from the study, and he/she considers the event to be reasonably related to the study intervention or study participation, the investigator must promptly notify alexion. the method of recording, evaluating, and assessing causality of ae and sae and the procedures for completing and transmitting sae reports are provided in section 10.3. care will be taken not to introduce bias when detecting aes and/or saes. open-ended and non-leading verbal questioning of the patient is the preferred method to inquire about ae occurrences. after the initial ae/sae report, the investigator is required to proactively follow-up on each patient at subsequent visits/contacts. all saes will be followed-up until resolution, stabilization, the event is otherwise explained, or the patient is lost to follow-up (as defined in section 7.3). further information on follow-up procedures is provided in section 10.3. • prompt notification of an sae by the investigator to alexion is essential so that legal obligations and ethical responsibilities towards the safety of patients and the safety of a study intervention under clinical investigation are met. • alexion has a legal responsibility to notify both the local regulatory authority and other regulatory agencies about the safety of a study intervention under clinical investigation. alexion will comply with country-specific regulatory requirements relating to safety reporting to the regulatory authority, institutional review board/independent ethics committee (irbs/iec), and investigators. • suspected unexpected serious adverse reactions (susars) must be reported according to local regulatory requirements and alexion policy and forwarded to investigators as necessary. • an investigator who receives an investigator safety report describing an sae or other specific safety information (eg, summary or listing of saes) from alexion will review and then file it along with the ib and will notify the (irb/iec), if appropriate according to local requirements. adverse events of special interest that will be monitored during this study are meningococcal infections. no cases of ravulizumab overdose have been reported during clinical studies. any dose of ravulizumab greater than that specified in the protocol will be considered an overdose. overdoses are medication errors that are not considered teaes unless there is an untoward medical occurrence resulting from the overdose. in the event of an overdose, the investigator or designee should: 1. contact the medical monitor immediately. 2. closely monitor the patient for any sae. 3. obtain a plasma sample for pk analysis if requested by the medical monitor (determined on a case-by-case basis). 4. document the quantity of the excess dose as well as the duration of the overdose in the crf/ecrf. samples will be collected from patients randomized to ravulizumab + bsc as specified in the soa (table 1) to determine serum concentrations of ravulizumab. the actual date and time (24-hour clock time) of each sample will be recorded. samples will be collected from all patients as specified in the soa (table 1) to assess the effect serum and plasma samples will be collected from all patients for biomarker analysis to evaluate complement activation and related pathways and cardiovascular health, and their clinical response to ravulizumab. these biomarkers include complement pathway proteins (eg, total and free c5, soluble c5b-9 [sc5b-9]), cytokines associated with inflammation and disease (eg, il-1, il-2r, il-6, il-8, il-21, tumor necrosis factor [tnf]-b, pentraxin-3, citrullinated histone h3, and monocyte chemoattractant protein [mcp]-1), factor ii, and markers associated with cardiovascular disease (procalcitonin, myoglobin, high sensitivity troponin i [hs-tni] and n-terminal pro-b-type natriuretic peptide [nt-probnp]). antibodies to alxn1210 (ie, antidrug antibody [ada]) will be evaluated in serum samples collected from patients randomized to ravulizumab + bsc according to the soa (table 1) . additionally, serum samples should also be collected at the final visit from patients who discontinued ravulizumab or were withdrawn from the study. these samples will be tested by alexion or alexion's designee. serum samples will be screened for antibodies binding to ravulizumab and the titer of confirmed positive samples will be reported. other analyses may be performed to further characterize the immunogenicity of ravulizumab. the detection and characterization of antibodies to ravulizumab will be performed using a validated assay method. samples collected for detection of antibodies to ravulizumab will also be evaluated for study intervention serum concentration to enable interpretation of the antibody data. confirmed antibody positive samples will be further evaluated for antibody titer and the presence of neutralizing antibodies. data collected during this study that may be used to conduct economic analyses include: • duration of hospitalization (total days or length of stay), • duration of icu stay (including total days), and • patient reported outcomes (eg, sf-12, version 2 and eq-5d-5l). protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 9. statistical considerations the primary null hypothesis is that there is no difference in survival between ravulizumab + bsc and bsc alone as measured by the difference in the proportions surviving at day 29 between the 2 treatment groups. the alternative hypothesis is that ravulizumab + bsc will improve survival at day 29 compared with bsc alone. the null hypotheses associated with the secondary objectives are that ravulizumab + bsc is no different than bsc alone for the respective endpoints; the alternative hypotheses are described below: 1. number of days free of mechanical ventilation: the alternative hypothesis is that treatment with ravulizumab + bsc will increase the number days free of mechanical ventilation at day 29 compared with bsc alone. the alternative hypothesis is that treatment with ravulizumab + bsc will reduce the number days in the icu at day 29 compared with bsc alone. 3. change in sofa score: the alternative hypothesis is that treatment with ravulizumab + bsc will improve changes in sofa score at day 29 compared with bsc alone. 4. change in spo2/fio2: the alternative hypothesis is that treatment with ravulizumab + bsc will improve changes in spo2/fio2 at day 29 compared with bsc alone. the alternative hypothesis is that treatment with ravulizumab + bsc will reduce the number days in the hospital at day 29 compared with bsc alone. 6. survival (based on all-cause mortality) at day 60 and day 90: the alternative hypothesis is that ravulizumab + bsc will improve survival at day 60 and day 90 compared with bsc alone. a sample size of 243 patients (162 ravulizumab + bsc, 81 bsc alone) is required to ensure at least 90% power and detect an improvement in survival from 60% in the bsc alone group to 80% in the ravulizumab + bsc group at day 29. this sample size calculation assumes: • 1-sided z-test of the difference in 2 proportions, • type i error = 0.025, • pooled variance, • 2:1 randomization on the 2 treatment groups, protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 • one interim analysis at 50% information which will be after collecting primary efficacy data on approximately 122 patients. the early stopping boundaries for efficacy and futility (nonbinding) will be constructed using α-spending function as lan-demets spending function with o'brien-fleming flavor and β-spending function as gamma(-4) (lan, 1983; hwang, 1990) . considering a nonevaluable rate of 10%, this study is planned to randomize approximately 270 patients (180 ravulizumab + bsc, 90 bsc alone). the population sets used for analysis sets are defined in the following: the itt consists of all randomized patients and participants will be analyzed as randomized. the itt will be used for the analysis of efficacy data and is considered the primary analysis population. the pps is a subset of the itt without any important protocol deviations that could impact efficacy analyses. determination of applicable important protocol deviations for this purpose will be made prior to database lock. the pps will be used for sensitivity analyses of the primary and secondary efficacy endpoints. safety set (ss) the ss consists of all randomized patients who receive at least 1 dose of ravulizumab for patients randomized to ravulizumab + bsc or who were randomized to bsc alone. the ss will be used for the analysis of safety data. abbreviation: bsc = best supportive care. the primary analysis will be conducted when all patients have completed the primary evaluation period. this analysis will include all efficacy, safety, and available pk/pd/immunogenicity study data for regulatory submission purposes and will be the final analysis of the primary evaluation period. summary statistics will be presented by treatment group and by visit, where applicable. descriptive statistics for continuous variables will minimally include the number of patients, mean, standard deviation, median, minimum, and maximum. for categorical variables, frequencies and percentages will be presented. graphical displays will be provided as appropriate. all statistical analyses will be performed based on a 2-sided type i error of 5%, unless otherwise noted. baseline is defined as the last available assessment on or before day 1 for all patients. day 1 will be defined as the date of the first infusion of ravulizumab for patients randomized and dosed with ravulizumab and as the date of randomization for patients randomized but not dosed with ravulizumab. analyses will be performed using sas ® software version 9.4 or higher. protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 9.4.1. efficacy analyses the primary efficacy endpoint is survival (based on all-cause mortality) at day 29 and will be compared between the 2 treatment groups using a 1-sided mantel-haenszel (mh) test of the difference in 2 proportions stratified by intubated or not intubated on day 1 and a type i error of 0.025. the estimated mh risk difference will be summarized along with the 95% confidence interval using mantel-haenszel stratum weights (mantel, 1959) and the sato variance estimator (sato, 1989) . missing survival data for the primary analysis will be imputed using a multiple imputation approach assuming the data are missing at random (mar) using a logistic regression model with covariates for treatment group, the randomization stratification factor, age, sex, and presence of a pre-existing condition at baseline. sensitivity analyses will include the worst-case, all available, and best-case scenarios. survival will also be analyzed using the method of kaplan and meier (km) and compared using a log-rank test stratified by intubated or not intubated on day 1 as a sensitivity analysis. hazard ratio and risk reduction will be summarized from a cox proportional hazards model stratified by intubated or not intubated on day 1. confidence intervals (95%) will be presented for the survival estimate at day 29 based on the complementary log-log transformation. kaplan-meier curves for both treatment groups will be produced. a sensitivity analysis of the primary endpoint will also be performed using a 3-level categorical outcome of 3) alive and discharged from the icu; 2) alive and in the icu or 1) death. the 2 treatment groups will be compared using an ordinal logistic regression with covariates for treatment group and the randomization stratification factor. additional sensitivity analyses will include statistical models adjusting for age, randomization stratification factor, and other important baseline covariates. subgroup analyses will also be performed by age group, randomization stratification factor, and other important baseline covariates. the statistical analysis plan (sap) will describe the sensitivity and subgroup analyses in greater detail. an interim analysis of the primary endpoint will also be conducted as described in section 9.5. number of days free of mechanical ventilation at day 29 will be compared between treatment groups using an analysis of covariance (ancova), adjusting for age, and randomization stratification factor, among survivors. missing data will be imputed using a multiple imputation approach assuming the data are mar. sensitivity analyses will include the worst-case, all available, and best-case scenarios. duration of icu stay at day 29 will be compared between treatment groups using an ancova, adjusting for age and randomization stratification factor, among survivors. missing data will be imputed using a multiple imputation approach assuming the data are mar. sensitivity analyses will include the worst-case, all available, and best-case scenarios. changes in sofa score from day 1 to day 29 will be summarized by treatment group and study visit for all patients and will be analyzed using a mixed model for repeated measures (mmrm) with baseline sofa score, age, randomization stratification factor, treatment group indicator, protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 study day (days 5, 10, 15, 22, and 29) , and study day by treatment group interaction as covariates. sensitivity analyses will include imputations for missing data. change from baseline in spo2/fio2 at day 29 will be analyzed using a mmrm with baseline spo2/fio2, age, randomization stratification factor, treatment group indicator, study day (days 5, 10, 15, 22, and 29) , and study day by treatment group interaction as covariates. all patients will be included in the model. sensitivity analyses will include imputations for missing data. change from baseline in pao2/fio2 at day 29 will also be analyzed using a mmrm with baseline pao2/fio2, age, randomization stratification factor, treatment group indicator, study day, and study day by treatment group interaction as fixed covariates. all patients will be included in the model. sensitivity analyses will include imputations for missing data. duration of hospitalization at day 29 will be analyzed in a similar manner as duration of icu stay. survival (based on all-cause mortality) at day 60 and day 90 will be estimated using the km method and compared using a log-rank test stratified by intubated or not intubated on day 1. hazard ratio and risk reduction will be summarized from a cox proportional hazards model stratified by intubated or not intubated on day 1. confidence intervals (95%) will be presented for the survival estimates at day 60 and day 90 based on the complementary loglog transformation. kaplan and meier curves for both treatment groups will be produced. a closed testing procedure will be applied to control the type i error for the analyses of the primary and secondary endpoints. if the primary endpoint is statistically significant in favor of ravulizumab, the secondary endpoints will be evaluated according to the following rank order: the hypothesis testing will proceed from highest rank (#1) the number of days free of mechanical ventilation at day 29 to the lowest rank (#5) duration of hospitalization at day 29, and if statistical significance is not achieved at an endpoint (p≥0.05), then endpoints of lower rank will not be considered to be statistically significant. confidence intervals and p-values will be presented for all secondary efficacy endpoints for descriptive purposes, regardless of the outcome of the closed testing procedure. an additional secondary endpoint will be assessed beyond day 29 regardless of the results of the closed testing procedure: survival (based on all-cause mortality) at day 60 and day 90. all safety analyses will be made on the safety set (ss). safety results will be reported by treatment group. the analysis and reporting of aes and saes will be based on teaes and tesaes, defined as aes and saes with onset during or after treatment with ravulizumab. the incidence of teaes and tesaes will be summarized by system organ class and preferred term, with additional summaries showing relationship to ravulizumab, severity, teaes or tesaes leading to ravulizumab discontinuation, and tesaes resulting in death. laboratory measurements as well as their changes from baseline at each visit and shift from baseline, if applicable, will be summarized. vital sign measurements, physical examination findings, and ecg data will also be summarized over time. all patients who have evaluable pk/pd data will be used to summarize pk/pd parameters for ravulizumab. descriptive statistics of ravulizumab concentration data will be presented for patients randomized and treated with ravulizumab for each scheduled sampling timepoint. total and free c5 concentrations will be evaluated by assessing the absolute values and changes and percentage changes from baseline, as appropriate. descriptive statistics will be presented by treatment group and for each scheduled sampling timepoint. serum and plasma biomarkers' actual values, and changes from baseline, and their association with observed clinical responses to ravulizumab will be summarized over time, as appropriate. biomarker data will only be summarized at the final analysis at the end of the study. the incidence and titers for adas to ravulizumab will be summarized in tabular format by treatment group. the proportion of patients ever positive and the proportion of patients always negative may be explored. confirmed ada positive samples will be evaluated for the presence of neutralizing antibodies. incidence of and time to progression to renal failure requiring dialysis at day 29 will be analyzed in a similar manner as the primary endpoint. time to clinical improvement will be analyzed using the km method and compared using a log-rank test stratified by intubated or not intubated on day 1. the sf-12 pcs and mcs scores and eq-5d-5l index and vas scores will be analyzed using an ancova, adjusting for age and the randomization stratification factor. an interim analysis for efficacy and futility will be conducted when approximately 122 patients have completed day 29. if the stopping criteria are met, the study may be terminated early for efficacy or futility depending on which stopping boundary is crossed. the early stopping boundaries for efficacy and futility (nonbinding) will be constructed using α-spending function as lan-demets (o'brien-fleming) spending function and β-spending function as gamma (-4). a 1-sided t-test based on the results from combining all imputed datasets for overall inference will be used with an overall type i error of 0.025. the sap will describe the planned interim analyses in greater detail. provided the study was not stopped early for efficacy or futility, the final primary analysis will be conducted when all patients have completed the primary evaluation period. this analysis will include all efficacy, safety, and available pk/pd/immunogenicity study data for regulatory submission purposes. this analysis will not be considered an interim analysis. an independent data monitoring committee (dmc), comprising experts in relevant fields with no direct relationship to the study, will be appointed by alexion. a minimum of 3 experts (including 1 biostatistician) will be selected. the dmc will review and evaluate cumulative safety data and key efficacy data at prespecified intervals. the dmc's purview will include recommendations to continue or terminate the study. final decisions regarding study conduct will be made by alexion. substantive decisions will be communicated to investigators, irbs/iecs, and appropriate regulatory authorities. the specific responsibilities of the dmc including frequency of meetings will be described in the dmc charter. • the protocol, protocol amendments, icf, ib, and other relevant documents (eg, advertisements) must be submitted to an irb/iec by the investigator and reviewed and approved by the irb/iec before the study is initiated. • any amendments to the protocol will require irb/iec approval before implementation of changes made to the study design, except for changes necessary to eliminate an immediate hazard to study patients. • for studies to be approved by medicines and healthcare products regulatory agency: the investigator will notify the irb/iec of deviations from the study protocol or gcp as defined by uk legislation as a serious breach or as required by irb/iec procedures. • the investigator will be responsible for the following: − providing written summaries of the status of the study to the irb/iec annually or more frequently in accordance with the requirements, policies, and procedures established by the irb/iec investigators or designees and sub-investigators will provide alexion with sufficient, accurate financial information as requested to allow alexion to submit complete and accurate financial certification or disclosure statements to the appropriate regulatory authorities. investigators are responsible for providing information on financial interests during the course of the study and for 1 year after completion of the study. • it is the responsibility of the investigator or designee to obtain informed consent from all patients or their legally acceptable representative as defined per local and country regulations where the study is taking place, and answer all questions regarding the study, prior to any study related procedures including screening assessments. • where applicable by national laws and allowed by local regulations, and following irb/iec approval, patients who are unable to provide informed consent, and whose legally acceptable representative is unavailable, can be enrolled per the judgement of the investigator or designee. • in the exceptional circumstance where informed consent cannot be obtained because of an inability to communicate with, or obtain legally effective consent from the patient and time is not sufficient to obtain consent from the patient's legally acceptable representative, the following procedure should be followed: − written certification from the investigator and a physician who is not involved with the research must be submitted to the irb/iec within 5 working days after administration of the initial dose. − if the patient is enrolled without their consent or that of their legally acceptable representative, all reasonable attempts should be made to inform the patient or their legally acceptable representative and/or family of the patient's enrollment in the study as soon as possible. − document efforts to contact the legally acceptable representative in the study records. • the investigator or designee will explain the nature of the study (including but not limited to the objectives, potential benefits and risks, inconveniences, and the patient's rights and responsibilities) to the patient or his/her legally acceptable representative, defined according to local and country regulations where the study is taking place, and answer all questions regarding the study. • patients must be informed that their participation is voluntary. patients or their legally acceptable representative will be required to sign a statement of informed consent or a certified translation if applicable, that meets the requirements of 21 cfr 50, local regulations, eu general data protection regulation, ich guidelines, health insurance portability and accountability act requirements, where applicable, and the irb/iec or study center. • the patient's medical record must include a statement that informed consent was obtained before the patient was screened in the study (or as soon as feasible in the case of emergency enrollment by the investigator or designee) and date the written consent was obtained. the authorized person obtaining the informed consent must also sign the icf(s). approved protocol and any other study agreements, ich gcp, and all applicable regulatory requirements. − due to the covid-19 pandemic, remote source data verification may be employed where permitted by local regulations. − the scope of the source data verification will be described in detail in the monitoring plan. • records and documents, including signed icfs, pertaining to the conduct of this study must be retained by the investigator for 2 years after the last marketing application approval, or if not approved, 2 years following the discontinuance of the study intervention, unless local regulations or institutional policies require a longer retention period. no records may be destroyed during the retention period without the written approval of alexion. no records may be transferred to another location or party without written notification to alexion. source documents provide evidence for the existence of the patient and substantiate the integrity of the data collected. the investigator or designee will prepare and maintain adequate and accurate source documents (eg, medical records, ecgs, ae and concomitant medication reporting, raw data collection forms) designed to record all observations and other pertinent data for each patient. data reported on the crf/ecrf that are transcribed from source documents must be consistent with the source documents or the discrepancies must be explained. the investigator may need to request previous medical records or transfer records, depending on the study. also, current medical records must be available. source documents are filed at the investigator's site. the study start date is the date on which the first patient is consented. alexion reserves the right to close the study site or terminate the study at any time for any reason at the sole discretion of alexion. study sites will be closed after the study is completed or following the decision to close or terminate the study. a study site is considered closed when all patients have completed the end of study or et visit, all data have been collected and entered into electronic data capture (edc) system, all required documents and study supplies have been collected, and a study-site closure visit has been performed. the investigator may initiate study-site closure at any time, provided there is reasonable cause and sufficient notice is given in advance of the intended termination. reasons for the early closure of a study site by alexion or investigator may include but are not limited to: • failure of the investigator to comply with the protocol, the requirements of the irb/iec or local health authorities, alexion's procedures, or gcp guidelines • inadequate recruitment of patients by the investigator if the study is prematurely terminated or suspended, alexion shall promptly inform the investigators, the irbs/iecs, the regulatory authorities, and any contract research organization(s) used in the study of the reason for termination or suspension, as specified by the applicable regulatory requirements. the investigator shall promptly inform the patient and should assure appropriate patient therapy and/or follow-up. • where possible, primary manuscripts reporting results of the primary efficacy endpoint or the final results will be submitted for publication within 12 to 18 months of the primary evaluation date or end of study, whichever is earlier. • investigators who participate as authors in manuscripts derived from alexion-sponsored studies will agree to the prerequisites as outlined in the alexion author engagement agreement prior to engaging in manuscript development. • the investigator agrees to submit proposals for new manuscripts (whether or not the proposed analyses are derived from protocol-specified endpoints) to alexion for review and consideration. all manuscripts or abstracts emanating from approved proposals are to be submitted to alexion for review before submission to the journal/society. this allows alexion to protect proprietary information and to provide comments. − the proprietary nature of some development work may preclude publication. in some cases, it may be necessary to delay a publication to allow alexion to ensure protection of intellectual property. • in general, primary publications, including congress and journal publications, containing the protocol-specified results of a study should occur prior to the publication of individual study site results or case reports. alexion's policy prohibits duplicate publication, whereby the same results must not be published in multiple peer-reviewed journal manuscripts. − encore congress publications may be appropriate to allow communication of research findings to relevant audience and geographical regions. • alexion will comply with the requirements for publication of study results. in accordance with standard editorial and ethical practice, alexion will generally support publication of multicenter studies only in their entirety and not as individual site data. in this case, a coordinating investigator will be designated by mutual agreement. • authorship will be determined by mutual agreement and in line with international committee of medical journal editors authorship requirements and per the alexion publication policy. • the tests listed in table 9 may be performed by the local or central laboratory, as appropriate for all patients unless otherwise noted. • protocol-specific requirements for inclusion or exclusion of patients are detailed in section 5 of the protocol. • additional tests may be performed at any time during the study as determined necessary by the investigator or required by local regulations. • women of childbearing potential should only be enrolled after a negative serum or urine pregnancy test result at screening. additional serum or urine pregnancy testing will be employed as required by site policies, local regulations, or per the requirements of the irb/iec and should be performed per the timepoints specified in the soa (table 1) . • investigators must document their review of each laboratory safety report. clinically significant findings resulting in an assessment of a tesae should be recorded on the ae crf/ecrf. • an ae is any untoward medical occurrence in a patient, temporally associated with the use of study intervention, whether or not considered related to the study intervention. • note: an ae can therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease (new or exacerbated) temporally associated with the use of study intervention. events meeting the ae definition • any abnormal laboratory test results (hematology, clinical chemistry, or urinalysis) or other safety assessments (eg, ecg, radiological scans, vital signs measurements), including those that worsen from baseline, considered clinically significant in the medical and scientific judgment of the investigator (ie, not related to progression of underlying disease). • exacerbation of a chronic or intermittent pre-existing condition including either an increase in frequency and/or intensity of the condition. • new conditions detected or diagnosed after study intervention administration even though it may have been present before the start of the study. • signs, symptoms, or the clinical sequelae of a suspected drug-drug interaction. • signs, symptoms, or the clinical sequelae of a suspected overdose of either study intervention or a concomitant medication. overdose per se will not be reported as an ae/sae unless it is an intentional overdose taken with possible suicidal/self-harming intent. such overdoses should be reported regardless of sequelae. • "lack of efficacy" or "failure of expected pharmacological action" per se will not be reported as an ae or sae. such instances will be captured in the efficacy assessments. however, the signs, symptoms, and/or clinical sequelae resulting from lack of efficacy will be reported as ae or sae if they fulfill the definition of an ae or sae. • medical or surgical procedure (eg, endoscopy, appendectomy): the condition that leads to the procedure is the ae. situations in which an untoward medical occurrence did not occur (eg, hospitalization for elective surgery if planned before the signing the icf, admissions for social reasons or for convenience). • anticipated day-to-day fluctuations of pre-existing disease(s) or condition(s) present or detected at the start of the study that do not worsen. • a medication error (including intentional misuse, abuse, and overdose of the product) or use other than what is defined in the protocol is not considered an ae unless there is an untoward medical occurrence as a result of a medication error. • cases of pregnancy that occur during maternal or paternal exposure to study intervention are to be reported within 24 hours of investigator/site awareness. data on fetal outcome and breastfeeding will be collected for regulatory reporting and safety evaluation. • any clinically significant abnormal laboratory findings or other abnormal safety assessments which are associated with the underlying disease, unless judged by the investigator to be more severe than expected for the patient's condition. • the disease/disorder being studied or expected progression, signs, or symptoms of the disease/disorder being studied, unless more severe than expected for the patient's condition. • situations in which an untoward medical occurrence did not occur (social and/or convenience admission to a hospital). • when further information becomes available, the edc should be updated within 24 hours with the new information and an updated sae report should be submitted to alexion global drug safety (gds). • after the study is completed at a given site, the electronic data collection tool will be taken off-line to prevent the entry of new data or changes to existing data. • if a site receives a report of a new sae from a study patient or receives updated data on a previously reported sae after the electronic data collection tool has been taken off-line, then the site can report this information on a paper sae form (see next section) or to the alexion/medical monitor/sae coordinator by telephone. • all saes will be recorded and reported to alexion or designee immediately and within 24 hours awareness. • saes will be reported using the safety reporting form and submitted to alexion gds. the investigator must complete, sign, and date the sae pages, verify the accuracy of the information recorded on the sae pages with the corresponding source documents, and send a copy via email or facsimile to the contact information provided below: − email: or fax: • additional follow-up information, if required or available, should be entered into the crf/ecrf and sent to alexion gds within 24 hours of the investigator or study site staff becoming aware of this additional information via the reporting process outlined above. • for all saes, the investigator must provide the following: − appropriate and requested follow-up information in the time frame detailed above − causality of the sae(s) − treatment of/intervention for the sae(s) − outcome of the sae(s) − medical records and laboratory/diagnostic information • all paper forms and follow-up information submitted to alexion gds must be accompanied by a cover page signed by the investigator. • paper source documents and/or reports should be kept in the appropriate section of the study file. female patients randomized to ravulizumab + bsc must not donate ova from the day 1 visit until 8 months after treatment with the last infusion of study drug. contraception is the responsibility of the heterosexually active male patients, regardless of his female partner's method of contraception. male patients who have had a vasectomy > 6 months prior must use a condom during heterosexual intercourse. male patients who have had a vasectomy < 6 months prior must use a condom and spermicide during heterosexual intercourse. male patients who have not had a vasectomy must use a condom and spermicide during heterosexual intercourse from the day 1 visit until 8 months after treatment with the last infusion of study drug. sexual abstinence is considered a highly effective method only if defined as refraining from heterosexual intercourse. in this study, abstinence is only acceptable if consistent with the patients' s preferred and usual lifestyle. abstinent male patients who become heterosexually active must use a condom and spermicide during intercourse. periodic abstinence (eg, calendar, symptothermal, or post-ovulation methods for a female partner) is not considered a highly effective method of contraception for male patients. male patients randomized to ravulizumab + bsc must not donate sperm from the day 1 visit until 8 months after treatment with the last infusion of study drug. pregnancy data will be collected during this study for all female patients and female spouses/partners of male patients. exposure during pregnancy (also referred to as exposure in utero) can be the result of either maternal exposure or transmission of study intervention via semen following paternal exposure. if a female patient or a male patient's female partner becomes pregnant during the conduct of this study, the investigator must submit the "pregnancy reporting and outcome/breastfeeding" form to alexion gds via facsimile or email. when the outcome of the pregnancy becomes known, the form should be updated and submitted to alexion gds. if additional follow-up is required, the investigator will be requested to provide the information. exposure of an infant to study intervention during breastfeeding must also be reported (via the "pregnancy reporting and outcome form/breastfeeding") and any aes experienced by the infant must be reported to alexion gds or designee via email or facsimile. pregnancy is not regarded as an ae unless there is a suspicion that the study intervention may have interfered with the effectiveness of a contraceptive medication. however, complications of pregnancy and abnormal outcomes of pregnancy are aes and may meet the criteria for an sae (eg, ectopic pregnancy, spontaneous abortion, intrauterine fetal demise, neonatal death, or congenital anomaly). elective abortions without complications should not be reported as aes. anaphylaxis is highly likely when any 1 of the following 3 criteria is fulfilled: • acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula), and at least 1 of the following: o respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia) o reduced blood pressure or associated symptoms of end-organ dysfunction (eg, hypotonia [collapse], syncope, incontinence) • two or more of the following that occur rapidly after exposure to a likely allergen for that participant (minutes to several hours): o involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips/tongue/uvula) o respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia) o reduced blood pressure or associated symptoms (eg, hypotonia [collapse], syncope, incontinence) o persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting) • reduced blood pressure after exposure to known allergen for that participant (minutes to several hours): o systolic blood pressure of less than 90 mmhg or greater than 30% decrease from that participant's baseline source: (sampson, 2006) appendix 6: management of potential drug infusion reactions prior to first menses 2. postmenopausal, as documented by amenorrhea for at least 1 year prior to the day 1 visit and fsh serum levels consistent with postmenopausal status of contraception, including at least one of the following: 1. intrauterine device (without copper) in place for at least 6 weeks. 2. progestogen-only hormonal contraception (either oral, injectable combined (estrogen-and progestogen-containing) hormonal contraception (either oral, intravaginal, or transdermal) for at least 6 weeks. estrogen-containing hormonal contraception is acceptable only if it has been used for at least 6 weeks immediately prior to the day 1 visit. estrogen-containing hormonal contraception may not be initiated during the study period surgical sterilization of the male partner (medical assessment of azoospermia is required if vasectomy was performed within the prior 6 months) abstinent female patients who wish to initiate a highly effective method of contraception during the study must refrain from heterosexual intercourse for at least 1 menstrual cycle. b. periodic abstinence (eg, calendar, symptothermal other methods of contraception that are not considered highly effective for female patients: 1. barrier methods, such as male or female condoms, diaphragm, or cervical cap spermicides or spermicidal sponges, used alone or in combination with barrier methods, are not acceptable a core outcome set for critical care ventilation trials pure red-cell aplasia and antierythropoietin antibodies in patients treated with recombinant erythropoietin covid-19) situation summary eq-5d-5l user guide complement activation contributes to severe acute respiratory syndrome coronavirus pathogenesis. mbio association of complement activation and elevated plasma-c5a with adult respiratory distress syndrome. pathophysiological relevance and possible prognostic value group sequential designs using a family of type i error probability spending functions mannose-binding lectin in severe acute respiratory syndrome coronavirus infection a shorter form health survey: can the sf-12 replicate results from the sf-36 longitudinal studies? blockade of the c5a-c5ar axis alleviates lung damage in hdpp4-transgenic mice infected with mers-cov variable eculizumab clearance requires pharmacodynamic monitoring to optimize therapy for thrombotic microangiopathy after hematopoietic stem cell transplantation the sofa score -development, utility and challenges of accurate assessment in clinical trials discrete sequential boundaries for clinical trials transplant-associated thrombotic microangiopathy is a multifactorial disease unresponsive to immunosuppressant withdrawal statistical aspects of analysis of data from retrospective studies of disease covid-19: consider cytokine storm syndromes and immunosuppression the comparative pathology of severe acute respiratory syndrome and avian influenza a subtype h5n1-a review serum concentrations of complement anaphylatoxins and proinflammatory mediators in patients with 2009 h1n1 influenza serum proteomic fingerprints of adult patients with severe acute respiratory syndrome calculating sofa scores when arterial blood gasses are not available: validating spo2/fio2 ratios for imputing pao2/fio2 ratios in the sofa score characterization of a novel coronavirus associated with severe acute respiratory syndrome second symposium on the definition and management of anaphylaxis: summary report--second national institute of allergy and infectious disease/food allergy and anaphylaxis network symposium on the variance estimator of the mantel-haenszel risk difference. letter to the editor the glasgow coma scale inhibition of complement activation alleviates acute lung injury induced by highly pathogenic avian influenza h5n1 virus infection use of the sofa score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study the role of c5a in acute lung injury induced by highly pathogenic viral infections remdesivir in adults with severe covid-19: a randomised, double-blind, placebo-controlled, multicentre trial sf-12: how to score the sf-12 physical and mental health summary scales clinical management of severe acute respiratory infection when novel coronavirus (2019-ncov) infection is suspected. interim guidance plasma inflammatory cytokines and chemokines in severe acute respiratory syndrome autoantibodies against human epithelial cells and endothelial cells after severe acute respiratory syndrome (sars)-associated coronavirus infection isolation of a novel coronavirus from a man with pneumonia in saudi arabia determine complement activation in patients randomized to bsc alone. the actual date and time (24-hour clock time) of each sample will be recorded. genetics will not be evaluated in this study.protocol amendment 3 (global)alxn1210-cov-305 09 jun 2020• patients must be reconsented to the most current version of the icfs during their participation in the study.• a copy of the icf must be provided to the patient or the patient's legally acceptable representative, as applicable. this document may require translation into the local language. documentation of icfs must remain in each patient's study file and must be available for verification at any time. • patients will be assigned a unique identifier by alexion. any patient records or datasets that are transferred to alexion will contain the identifier only; patient names or any information which would make the patient identifiable will not be transferred.• patients or their legally acceptable representative must be informed that their personal study-related data will be used by alexion in accordance with local data protection law. the level of disclosure must also be explained to the patients who will be required to give consent for their data to be used as described in the informed consent.• patients or their legally acceptable representative must be informed that their medical records may be examined by clinical quality assurance auditors or other authorized personnel appointed by alexion, by appropriate irb/iec members, and by inspectors from regulatory authorities. study-related information and study results may be posted on publicly accessible clinical study databases (eg, the us website www.clinicaltrials.gov or the eu website www.clinicaltrialsregister.eu), as appropriate, and in accordance with national, regional, and local regulations. • all patient data relating to the study will be recorded on printed or ecrf unless transmitted to alexion or designee electronically (eg, laboratory data). the investigator is responsible for verifying that data entries are accurate and correct by physically or electronically signing the ecrf.• the investigator must maintain accurate documentation (source data) that supports the information entered in the crf/ecrf.• the investigator must permit study-related monitoring, audits, irb/iec review, and regulatory agency inspections and provide direct access to source data documents.• alexion or designee is responsible for the data management of this study including quality checking of the data.• study monitors will perform ongoing source data verification to confirm that data entered into the crf/ecrf by authorized site personnel are accurate, complete, and verifiable from source documents; that the safety and rights of patients are being protected; and that the study is being conducted in accordance with the currently protocol amendment 3 (global)alxn1210-cov-305 09 jun 2020 protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 il1, il-2r, il-6, il-8,il-21, pentraxin-3, and citrullinated histone h3 total and free c5 and sc5b-9 procalcitonin myoglobin nt-probnp hs-tni immunogenicity assay (only collect from patients randomized to ravulizumab + bsc) pharmacokinetic assay (only collect from patients randomized to ravulizumab + bsc) factor ii abbreviations: bsc = best supportive care; c = complement protein; hs-tni = high sensitivity troponin i; il = interleukin, mcp = monocyte chemoattractant protein; nt-probnp = n-terminal pro b-type natriuretic peptide; sc5b-9 = soluble c5b-9; tnf = tumor necrosis factor; wbc = white blood cell.protocol amendment 3 (global)alxn1210-cov-305 09 jun 2020 if an event is not an ae per definition above, then it cannot be an sae even if serious conditions are met (eg, hospitalization for signs/symptoms of the disease under study, death due to progression of disease).an sae is defined as any untoward medical occurrence that, at any dose: 1. results in death 2. is life-threatening the term "life-threatening" in the definition of "serious" refers to an event in which the patient was at risk of death at the time of the event. it does not refer to an event, which hypothetically might have caused death, if it was more severe. in general, hospitalization signifies that the patient has been detained (usually involving at least an overnight stay) at the hospital or emergency ward for observation and/or treatment that would not have been appropriate in the physician's office or outpatient setting. complications that occur during hospitalization are aes. if a complication prolongs hospitalization or fulfills any other serious criteria, the event is serious. when in doubt as to whether "hospitalization" occurred or was necessary, the ae should be considered serious. hospitalization for elective treatment of a pre-existing condition that did not worsen from baseline is not considered an ae. • the term disability means a substantial disruption of a person's ability to conduct normal life functions.• this definition is not intended to include experiences of relatively minor medical significance such as uncomplicated headache, nausea, vomiting, diarrhea, influenza, and accidental trauma (eg, sprained ankle) which may interfere with or prevent everyday life functions but do not constitute a substantial disruption. 5. is a congenital anomaly/birth defect 6. other situations:• medical or scientific judgment should be exercised in deciding whether sae reporting is appropriate in other situations such as important medical events that may not be immediately life-threatening or result in death or hospitalization but may jeopardize the patient or may require medical or surgical intervention to prevent one of the other outcomes listed in the above definition. these events should usually be considered serious.• examples of such events include invasive or malignant cancers, intensive treatment in an emergency room or at home for allergic bronchospasm, blood dyscrasias or convulsions that do not result in hospitalization, or development of drug dependency or drug abuse. • when an ae/sae occurs, it is the responsibility of the investigator to review all documentation (eg, hospital progress notes, laboratory reports, and diagnostics reports) related to the event. • the investigator will then record all relevant ae/sae information in the crf/ecrf. • it is not acceptable for the investigator to send photocopies of the patient's medical records to alexion in lieu of completion of the alexion/ae/sae crf/ecrf page. • there may be instances when copies of medical records for certain cases are requested by alexion. in this case, all patient identifiers, with the exception of the patient number, will be redacted on the copies of the medical records before submission to alexion. • the investigator will attempt to establish a diagnosis of the event based on signs, symptoms, and/or other clinical information. whenever possible, the diagnosis (not the individual signs/symptoms) will be documented as the ae/sae. the investigator will make an assessment of intensity for each ae and sae reported during the study and assign it to one of the following categories from national cancer institute ctcae v5.0, published 27 nov 2017: • grade 1: mild (awareness of sign or symptom, but easily tolerated) • grade 2: moderate (discomfort sufficient to cause interference with normal activities) protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020• grade 3: severe (incapacitating, with inability to perform normal activities) • grade 4: life-threatening • grade 5: fatal • an event is defined as "serious" when it meets at least one of the predefined outcomes as described in the definition of an sae, not when it is rated as severe. • the investigator is obligated to assess the relationship between the study intervention and each occurrence of each ae or sae. an investigator causality assessment must be provided for all aes (both nonserious and serious). this assessment must be recorded in the crf/ecrf and on any additional forms, as appropriate.the definitions for the causality assessments are as follows: − not related: there is no reasonable possibility the study intervention caused the ae.  the ae has a more likely alternative etiology; it may be due to underlying or concurrent illness, complications, concurrent treatments, or effects of another concurrent drug.  the event does not follow a reasonable temporal relationship to administration of the study intervention. − related: there is a reasonable possibility the study intervention caused the ae. the ae has a temporal relationship to the administration of the study intervention.  the event does not have a likely alternative etiology.  the event corresponds with the known pharmaceutical profile of the study intervention.  there is improvement on discontinuation and/or reappearance on rechallenge.• the investigator will use clinical judgment to determine the relationship.• alternative causes, such as underlying disease(s), concomitant therapy, and other risk factors, as well as the temporal relationship of the event to study intervention administration will be considered and investigated. • the investigator will also consult the ib and/or product information, for marketed products, in his/her assessment. • for each ae/sae, the investigator must document in the medical notes that he/she has reviewed the ae/sae and has provided an assessment of causality. • there may be situations in which an sae has occurred, and the investigator has minimal information to include in the initial report to alexion. however, it is very important that the investigator always make an assessment of causality for every event before the initial transmission of the sae data to alexion. • the investigator may change his/her opinion of causality in light of follow-up information and send an sae follow-up report with the updated causality assessment. • the causality assessment is one of the criteria used when determining regulatory reporting requirements. • the investigator is obligated to perform or arrange for the conduct of supplemental measurements and/or evaluations as medically indicated or as requested by alexion to elucidate the nature and/or causality of the ae or sae as fully as possible. this may include additional laboratory tests or investigations, histopathological examinations, or consultation with other health care professionals. • new or updated information will be recorded in the originally completed crf/ecrf. • the investigator will submit any updated sae data to alexion within 24 hours of receipt of the information. • all saes will be recorded and reported to alexion or designee immediately and within 24 hours of awareness. • the primary mechanism for reporting an sae to alexion will be the electronic data collection tool.• if the electronic system is unavailable at the time that the investigator or site becomes aware of an sae, the site will use the paper contingency form for sae reporting via fax or email. facsimile transmission or email may be used in the event of electronic submission failure. − email: or fax: • the site will enter the sae data into the edc system as soon as it becomes available. a woman is considered fertile following menarche and until becoming postmenopausal unless permanently sterile (see below).if fertility is unclear (eg, amenorrhea in adolescents or athletes) and a menstrual cycle cannot be confirmed before administering the dose of study intervention, additional evaluation should be considered.women in the following categories are not considered wocbp 1. premenarchal 2. premenopausal female with one of the following:• documented hysterectomy• documented bilateral salpingectomy• documented bilateral oophorectomy• for individuals with permanent infertility due to an alternate medical cause other than the above, (eg, mullerian agenesis, androgen insensitivity), investigator discretion should be applied to determining study entry.• note: documentation can come from the site personnel's: review of the patient's medical records, medical examination, or medical history interview. • a postmenopausal state is defined as no menses for 12 months without an alternative medical cause.− a high follicle stimulating hormone (fsh) level in the postmenopausal range may be used to confirm a postmenopausal state in women not using hormonal contraception or hormonal replacement therapy (hrt). however, in the absence of 12 months of amenorrhea, confirmation with more than 1 fsh measurement is required.• females on hrt and whose menopausal status is in doubt will be required to use one of the non-estrogen hormonal highly effective contraception methods if they wish to continue their hrt during the study. otherwise, they must discontinue hrt to allow confirmation of postmenopausal status before study enrollment. female patients of non-childbearing potential are exempt from contraception requirements. nonchildbearing potential for female patients is defined as any of the following:protocol amendment 3 (global) alxn1210-cov-305 09 jun 2020 any female patient who becomes pregnant while participating in the study will be discontinued from study intervention. • the investigator will attempt to collect pregnancy information on any male patient's female partner who becomes pregnant while the male patient is in this study. this applies only to male patients who receive ravulizumab.• after obtaining the necessary signed informed consent from the pregnant female partner directly, the investigator will record pregnancy information on the appropriate pregnancy outcome/breastfeeding form and submit it to alexion within 24 hours of learning of the partner's pregnancy. the female partner will also be followed to determine the outcome of the pregnancy. information on the status of the mother and child will be forwarded to alexion. generally, the follow-up will be no longer than 6 to 8 weeks following the estimated delivery date. any termination of the pregnancy will be reported regardless of fetal status (presence or absence of anomalies) or indication for the procedure. • the investigator will collect pregnancy information on any female patient who becomes pregnant while participating in this study. the initial information will be recorded on the appropriate form and submitted to alexion within 24 hours of learning of a patient's pregnancy.• the patient will be followed-up to determine the outcome of the pregnancy. the investigator will collect follow-up information on the patient and the neonate and the information will be forwarded to alexion. generally, follow-up will not be required for longer than 3 months beyond the estimated delivery date. any termination of pregnancy will be reported, regardless of fetal status (presence or absence of anomalies) or indication for the procedure.• while pregnancy itself is not considered to be an ae or sae, any pregnancy complication or elective termination of a pregnancy for medical reasons will be reported as an ae or sae. a spontaneous abortion (occurring at < 22 weeks gestational age) or still birth (occurring at > 22 weeks gestational age) is always considered to be an sae and will be reported as such. any post-study pregnancy related sae considered reasonably related to the study intervention by the investigator will be reported to alexion as described in section 8.6.4. while the investigator is not obligated to actively seek this information in former study patients, he or she may learn of an sae through spontaneous reporting.protocol amendment 3 (global)alxn1210-cov-305 09 jun 2020 appendix 5: biomarkers• blood samples will be collected for biomarker analyses and the data may be used for future exploratory research related to complement activation and inflammatory processes. the samples may also be used to develop tests/assays including diagnostic tests related to c5 inhibitors and covid-19 with clinical presentation of severe pneumonia, acute lung injury, or ards.• the samples may be analyzed as part of a multistudy assessment of biomarkers in the response to ravulizumab to understand covid-19 or related conditions.• the results of biomarker analyses may be reported in a final clinical study report or in a separate summary report.• alexion or designee will store the samples obtained for biomarker analyses in a secure storage space with adequate measures to protect confidentiality.protocol amendment 3 (global) intravenous and infusion-associated reactions are a potential risk with the use of monoclonal antibodies; these reactions can be nonimmune or immune mediated (eg, hypersensitivity reactions). signs and symptoms may include headache, fever, facial flushing, pruritus, myalgia, nausea, chest tightness, dyspnea, vomiting, erythema, abdominal discomfort, diaphoresis, shivers, hypertension, lightheadedness, hypotension, palpitations, and somnolence. signs and symptoms of hypersensitivity or allergic reactions may include hives, swollen face, eyelids, lips, or tongue, or trouble with breathing.all administration-, iv-, and infusion-associated reactions will be reported to the investigator and qualified designee. the investigator and qualified designee are responsible for detecting, documenting, and recording events that meet the definition of ae or sae and remain responsible for following up events that are serious, considered related to the study drug, or study procedures; or that caused the participant to discontinue ravulizumab (section 7).definitions and procedures for recording, evaluating, follow-up, and reporting aes and saes are outlined in section 10.3.before any infusion is started, the treating physician and other appropriate personnel must make certain that medication (ie, adrenaline, inhaled beta agonists, antihistamines, corticosteroids) and other equipment to treat anaphylaxis are readily available. the infusion must be stopped immediately if grade ≥ 2 allergic/hypersensitivity reactions (including drug fever) or grade ≥ 3 cytokine release syndrome/acute infusion reaction occurs. the sponsor must be notified within 24 hours of any infusion reaction requiring interruption or discontinuation of study drug.patients who experience a reaction during the administration of study drug should be treated according to institutional guidelines. for a grade 1 or grade 2 infusion reaction, the infusion should be temporarily stopped and treatment with an antihistamine (eg, diphenhydramine 25 to 50 mg orally or equivalent) and acetaminophen (650 mg orally or equivalent) may be considered. if the patient's signs and symptoms have resolved (with or without administration of the above medication), the infusion may be restarted. however, the patients should be infused at a slower rate and be monitored closely for any signs and symptoms of infusion reactions during the remainder of the infusion. patients experiencing an infusion reaction should be observed in the clinic until resolution of the reaction, or until the investigator determines the patient is no longer at risk. patients who experience a severe reaction during administration of study drug resulting in discontinuation of study drug should undergo all scheduled safety, pk, and pd evaluations required by the protocol.if anaphylaxis occurs according to the criteria listed below, then administration of subcutaneous epinephrine (1/1000, 0.3 ml to 0.5 ml, or equivalent) should be considered. in the case of bronchospasm, treatment with an inhaled beta agonist also should be considered. patients administered an antihistamine for the treatment or prevention of an infusion reaction should be given appropriate warnings about drowsiness and impairment of driving ability before being discharged from the center. key: cord-336000-v88bq4bx authors: barco, stefano; bingisser, roland; colucci, giuseppe; frenk, andré; gerber, bernhard; held, ulrike; mach, francois; mazzolai, lucia; righini, marc; rosemann, thomas; sebastian, tim; spescha, rebecca; stortecky, stefan; windecker, stephan; kucher, nils title: enoxaparin for primary thromboprophylaxis in ambulatory patients with coronavirus disease-2019 (the ovid study): a structured summary of a study protocol for a randomized controlled trial date: 2020-09-09 journal: trials doi: 10.1186/s13063-020-04678-4 sha: doc_id: 336000 cord_uid: v88bq4bx objectives: the ovid study will demonstrate whether prophylactic-dose enoxaparin improves survival and reduces hospitalizations in symptomatic ambulatory patients aged 50 or older diagnosed with covid-19, a novel viral disease characterized by severe systemic, pulmonary, and vessel inflammation and coagulation activation. trial design: the ovid study is conducted as a multicentre open-label superiority randomised controlled trial. participants: inclusion criteria 1. signed patient informed consent after being fully informed about the study’s background. 2. patients aged 50 years or older with a positive test for sars-cov2 in the past 5 days and eligible for ambulatory treatment. 3. presence of respiratory symptoms (i.e. cough, sore throat, or shortness of breath) or body temperature >37.5° c. 4. ability of the patient to travel to the study centre by private transportation, performed either by an accompanying person from the same household or by the patient themselves 5. ability to comply with standard hygiene requirements at the time of in-hospital visit, including a face mask and hand disinfectant. 6. ability to walk from car to study centre or reach it by wheelchair transport with the help of an accompanying person from the same household also complying with standard hygiene requirements. 7. ability to self-administer prefilled enoxaparin injections after instructions received at the study centre or availability of a person living with the patient to administer enoxaparin. exclusion criteria 1. any acute or chronic condition posing an indication for anticoagulant treatment, e.g. atrial fibrillation, prior venous thromboembolism (vte), acute confirmed symptomatic vte, acute coronary syndrome. 2. anticoagulant thromboprophylaxis deemed necessary in view of the patient's history, comorbidity or predisposing strong risk factors for thrombosis: a. any of the following events occurring in the prior 30 days: fracture of lower limb, hospitalization for heart failure, hip/knee replacement, major trauma, spinal cord injury, stroke, b. previous vte, c. histologically confirmed malignancy, which was diagnosed or treated (surgery, chemotherapy, radiotherapy) in the past 6 months, or recurrent, or metastatic, or inoperable. 3. any clinically relevant bleeding (defined as bleeding requiring hospitalization, transfusion, surgical intervention, invasive procedures, occurring in a critical anatomical site, or causing disability) within 30 days prior to randomization or sign of acute bleeding. 4. intracerebral bleeding at any time in the past or signs/symptoms consistent with acute intracranial haemorrhage. 5. haemoglobin <8 g/dl and platelet count <50 x 10(9) cells/l confirmed by recent laboratory test (<90 days). 6. subjects with any known coagulopathy or bleeding diathesis, including known significant liver disease associated with coagulopathy. 7. severe renal insufficiency (baseline creatinine clearance <30 ml/min calculated using the cockcroft-gault formula) confirmed by recent laboratory test (<90 days). 8. contraindications to enoxaparin therapy, including prior heparin-induced thrombocytopenia and known hypersensitivity. 9. current use of dual antiplatelet therapy. 10. participation in other interventional studies over the past 30 days. 11. non-compliance or inability to adhere to treatment or lack of a family environment or support system for home treatment. 12. cognitive impairment and/or inability to understand information provided in the study information. patient enrolment will take place at seven swiss centres, including five university hospitals and two large cantonal hospitals. intervention and comparator: patients randomized to the intervention group will receive subcutaneous enoxaparin at the recommended dose of 4,000 iu anti-xa activity (40 mg/0.4 ml) once daily for 14 days. patients randomized to the comparator group will receive no anticoagulation. main outcomes: primary outcome: a composite of any hospitalization or all-cause death occurring within 30 days of randomization. secondary outcomes: (i) a composite of cardiovascular events, including deep vein thrombosis (including catheter-associated), pulmonary embolism, myocardial infarction/myocarditis, arterial ischemia including mesenteric and extremities, acute splanchnic vein thrombosis, or ischemic stroke within 14 days, 30 days, and 90 days of randomization; (ii) each component of the primary efficacy outcome, within 14 days, 30 days, and 90 days of randomization; (iii) net clinical benefit (accounting for the primary efficacy outcome, composite cardiovascular events, and major bleeding), within 14 days, 30 days, and 90 days of enrolment; (iv) primary efficacy outcome, within 14 days, and 90 days of enrolment; (v) disseminated intravascular coagulation (isth criteria, in-hospital diagnosis) within 14 days, 30 days, and 90 days of enrolment. randomisation: patients will undergo block stratified randomization (by age: 50-70 vs. >70 years; and by study centre) with a randomization ratio of 1:1 with block sizes varying between 4 and 8. randomization will be performed after the signature of the informed consent for participation and the verification of the eligibility criteria using the electronic data capture software (redcap, vanderbilt university, v9.1.24). blinding (masking): in this open-label study, no blinding procedures will be used. numbers to be randomised (sample size): the sample size calculation is based on the parameters α = 0.05 (2-sided), power: 1−β = 0.8, event rate in experimental group, pexp = 0.09 and event rate in control group, pcon = 0.15. the resulting total sample size is 920. to account for potential dropouts, the total sample size was fixed to 1000 with 500 patients in the intervention group and 500 in the control group. trial status: protocol version 1.0, 14 april 2020. protocol version 3.0, 18 may 2020 recruiting start date: june 2020. last patient last visit: march 2021. trial registration: clinicaltrials.gov identifier: nct04400799 first posted: may 26, 2020 last update posted: july 16, 2020 full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file 1). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. 3.0 / 18.05.2020 pending clinical study with imp category b. clinical phase iiib. coronavirus disease (covid-19) has emerged as a pandemic and a public health crisis of global proportions. as of april 9, 2020, a total of 1,716,371 covid-19 cases have been diagnosed with the severe acute respiratory syndrome corona virus 2 (sars-cov-2) across more than 170 countries. of one of the most frequently described poor prognostic features in patients with covid-19 is the development of coagulopathy. an increase in d-dimers, which reflects the presence of disseminated intravascular coagulation, is usually observed in the most severe cases of covid-19 and it correlates with in-hospital mortality (2) (3) (4) . in hospitalized patients with sepsis-induced coagulopathy or with markedly elevated d-dimer associated with covid-19 infection, anticoagulation with low-molecular-weight heparin (lmwh) was associated with lower mortality. covid-19 emerged as a dramatic prothrombotic condition and it appears now clear, a few months after the first patients described in china, that covid-19 patients are characterized by a substantial risk of developing acute pulmonary embolism (pe) or deep vein thrombosis (dvt) due to local and systemic inflammation, reduced mobility, hypoxia, endothelial dysfunction. in particular, the cumulative incidence of vte in covid-19 patients is approximately 20-30% (up to 70% in icu patients undergoing vte screening). this contrasts with the risk of vte observed in medically ill patients (<3%). moreover, half of the vte events, mostly pe, were diagnosed at hospital admission, suggesting that these events developed during home quarantine. recent guidances stated that prophylactic-dose lmwh, such as enoxaparin, should be considered in all patients who require hospital admission for covid-19 in the absence of any contraindications. one of the better known non-anticoagulant properties of heparins, their anti-inflammatory function, include binding to inflammatory cytokines, inhibition of neutrophil chemotaxis and leukocyte migration, neutralization of the positively charged peptide complement factor c5a, and sequestering acute phase proteins: this may provide a benefit in covid infection where proinflammatory cytokines are markedly raised and acute respiratory distress syndrome represents a feared and life-threatening complication. covid-19 patients are characterized by systemic inflammation, reduced mobility, hypoxia, endothelial dysfunction, signs of myocarditis and heart failure, and the underlying coagulopathy, all factors increasing the risk of developing thromboembolic events. it remains unclear whether covid-19 patients not admitted to the hospital due to non-severe clinical conditions should receive thromboprophylaxis and whether this provides a clinical benefit weighed against the risk of anticoagulant-associated bleeding. the evidence is scarce also for non-covid-19 patients. the most recent american society of hematology (ash) guidelines state that "in medical outpatients with minor provoking risk factors for vte (eg, immobility, minor injury, illness, infection), the ash guideline panel suggests not using vte prophylaxis (conditional recommendation, very low certainty in the evidence of effect)." our hypothesis is that enoxaparin may prevent or limit coagulopathy, including the occurrence of thromboembolic events, in the presence of a mild covid disease in an outpatient setting. the ovid study will show whether prophylactic-dose enoxaparin improves survival and reduces any hospitalizations in ambulatory patients aged 50 or older diagnosed with covid-19, a novel viral disease characterized by severe systemic, pulmonary, and vessel inflammation and coagulation activation. the primary efficacy outcome is a composite of any hospitalization or all-cause death occurring within 30 days of randomization. the study will be conducted as a multicentre randomized open-label controlled trial. in the study, a total of 1,000 adult patients aged 50 or older with covid-19 and candidates to ambulatory treatment will be randomized to receive enoxaparin 40 mg sc qd or no treatment for a total of 14 days. the primary outcome will be assessed within 30 days of enrolment. inclusion criteria 1) signs patient informed consent after being fully informed about the study's background. 2) patients aged 50 years or older with a positive test for sars-cov2 in the past 5 days and eligible for ambulatory treatment. 3) presence of respiratory symptoms (i.e. cough, sore throat, or shortness of breath) or body temperature >37.5° c. 4) ability of the patient to travel to the study center by private transportation, performed either by accompanying person from same household or by the patient him/herself. 5) ability to comply with standard hygiene requirements at the time of in-hospital visit, including a face mask and hand disinfectant. 6) ability to walk from car to study center or reach it by wheel chair transport with the help of an accompanying person from the same household also complying with standard hygiene requirements. 7) ability to self-administer prefilled enoxaparin injections after instructions received at the study center or availability of a person living with the patient to administer enoxaparin. any acute or chronic condition posing an indication for anticoagulant treatment, e.g. atrial fibrillation, prior vte, acute confirmed symptomatic vte, acute coronary syndrome. anticoagulant thromboprophylaxis deemed necessary in view of the patient's history, comorbidity or predisposing strong risk factors for thrombosis: a. any of the following events occurring in the prior 30 days: fracture of lower limb, hospitalization for heart failure, hip/knee replacement, major trauma, spinal cord injury, stroke, b. previous vte, c. histologically confirmed malignancy, which was diagnosed or treated (surgery, chemotherapy, radiotherapy) in the past 6 months, or recurrent, or metastatic, or inoperable. any clinically relevant bleeding (defined as bleeding requiring hospitalization, transfusion, surgical intervention, invasive procedures, occurring in a critical anatomical site, or causing disability) within 30 days prior to randomization or sign of acute bleeding. intracerebral bleeding at any time in the past or signs/symptoms consistent with acute intracranial hemorrhage. hemoglobin <8 g/dl and platelet count <50 x 10 9 cells/l confirmed by recent laboratory test (<90 days). subjects with any known coagulopathy or bleeding diathesis, including known significant liver disease associated with coagulopathy. severe renal insufficiency (baseline creatinine clearance <30 ml/min calculated using the cockcroft-gault formula) confirmed by recent laboratory test (<90 days). 8) contraindications to enoxaparin therapy, including prior heparin-induced thrombocytopenia and known hypersensitivity. current use of dual antiplatelet therapy. 10) participation in other interventional studies over the past 30 days. non-compliance or inability to adhere to treatment or lack of a family environment or support system for home treatment. 12) cognitive impairment and/or inability to understand to information provided in the study information. we implemented two logistical solutions to integrate the process of sars-cov2 testing, pre-screening, screening (hot-line and flyers), in-hospital recruitment, enrolment and randomization/allocation. a nationwide ovid hot-line telephone number will be made available in 3 languages (german, french, italian) for interested patients or test centers to contact the hot-line. standard hygiene precautions will be met at the study centers to avoid spreading of sars-cov2 among other patients or health care workers. principles of patient and investigator safety will be applied. standard procedures concerning privacy, discussion with patients on details of the study, collection of informed consent, and instruction on how to administer the study medication will be maintained in conformity with gcp recommendations. this will also include outcome measurements to be conducted by telephone with standardized questionnaire. enoxaparin (clexane®) will be given at the recommended dose of 4,000 iu antixa activity (40 mg/0.4 ml) once daily by sc injection for 14 days. no study drug. the sample size calculation is based on the parameters = 0.05 (2sided), power = 1− = 0.8, event rate in experimental group, = 0.09 and event rate in control group, = 0.15. the resulting total sample size is 920. to account for potential drop-outs, the total sample size was fixed to 1000. this will be the maximum sample size, no increase in sample size is planned. results will be reported in terms of risk ratios (rr) between experimental and control group, i.e. we anticipate that the estimated rr will be < 1. we obtained official data on fatality and hospitalization rates observed in the swiss population until 31.03.2020: a total of 12.372 patients aged 50 years or older tested positive for sars-cov-2, of whom 645 (5.2%) died and 2.350 (19.0%) were hospitalized irrespective of whether this consisted of a primary hospitalization (after evaluation at the emergency department) or a secondary hospitalization for clinical deterioration after initial ambulatory treatment. assuming that two thirds of deaths and of any hospitalization occurred in ambulatory patients, we estimated that the primary efficacy outcome rate would occur in 15% (any hospitalization 11%, case fatality rate 4%). as we anticipate that a substantial number of the primary endpoint is due to venous or arterial thromboembolic complications, which would be prevented by the use of prophylactic-dose enoxaparin, we estimated that enoxaparin will decrease the primary efficacy outcome to 9% (rr 0.6). prior studies of thromboprophylaxis in hospitalized patients with medical illnesses were also considered for estimating the benefit of enoxaparin use in medical patients and sample size calculation. 10 months the primary efficacy outcome analysis will be conducted in the intention-to-treat (itt) population, consisting of all randomized subjects who signed a valid informed consent. descriptive statistics of the patient characteristics at baseline will include mean and standard deviation for continuous variables, median and interquartile range for the ordinal or non-normal variables, as well as numbers and percentages of total for the categorical variables. for the primary outcome, the relative risk will be calculated for the experimental group as compared to control group, with 95% confidence interval. refined analyses include the stratification variables in order to reduce unexplained heterogeneity. for that, the mantel haenszel method as well as multiple logistic regression models will be used. a single interim analysis is planned. the aim of the interim analysis is to stop the trial early for efficacy (superiority) or futility. this study will be conducted in compliance with the protocol, the current version of the declaration of helsinki, the ich-gcp guideline as well as all national legal and regulatory requirements. b. demographics, medical history. c. vital signs (respiratory rate, heart rate, arterial blood pressure, body temperature, arterial oxygen saturation), height, weight. d. laboratory tests (blood cell count, hemoglobin and creatinine). e. the dispense of study medication and the administration of the first dose will be done at the study center after appropriate instruction and under medical supervision. the following doses will be administered from an instructed person of the same household or self-administered at home until day 14. instructions on how to administer enoxaparin will also made be available in paper and video from the product manufacturer. f. any hospitalization or all-cause death. g. pulmonary embolism, myocardial infarction/myocarditis, arterial ischemia including mesenteric and extremities, acute splanchnic vein thrombosis, or ischemic stroke; major bleeding, non-major clinically relevant bleeding. before this study will be conducted, the protocol, the proposed participant information and consent form as well as other study-specific documents will be submitted to a properly constituted competent ethics committee (cec) and competent authorities (swissmedic) in agreement with local legal requirements, for formal approval. any amendment to the protocol must as well be approved. the decision of the cec and swissmedic concerning the conduct of the study will be made in writing to the sponsor-investigator before commencement of this study. the clinical study can only begin once approval from all required authorities has been received. any additional requirements imposed by the authorities shall be implemented. the study will be registered in the swiss federal complementary database (swiss national clinical trial portal (snctp) and in the international trial registry clinicaltrials.gov (clinicaltrials.gov). category b. the current label of enoxaparin (study medication) does not cover ambulatory patients with acute infectious diseases without additional venous thromboembolism (vte) risk factors. the efficacy and safety of prophylactic-dose enoxaparin has not been studied in covid-19 ambulatory patients, as sars-cov2 has been described first in 2019. approval from the appropriate constituted competent ethics committee is sought for each study site in the clinical trial. the reporting duties and allowed time frame are respected. no substantial amendments are made to the protocol without prior sponsor and cec approval, except where necessary to eliminate apparent immediate hazards to study participants. premature study end or interruption of the study is reported within 15 days. the regular end of the study is reported to the cec within 90 days, the final study report shall be submitted within one year after study end. amendments are reported according to chapter 2.10. the sponsor will obtain approval from swissmedic before the start of the clinical trial. reporting will be done within the allowed time frame. planned or premature study end are reported within 90 and 15 days, respectively. the final report will be submitted to the ca within one year after the end of the study. amendments are reported according to chapter 2.10. the study will be carried out in accordance with principles enunciated in the current version of the declaration of helsinki, the guidelines of good clinical practice (gcp) issued by ich, and swiss competent authority's requirements. cec and competent authorities will receive annual safety and interim reports and be informed about non-substantial amendments, the course of the study, and the study stop/ end in agreement with local requirements. no conflicts of interest. the investigator must explain to each participant the nature of the study, its purpose, the procedures involved, the expected duration, the potential risks and benefits and any discomfort it may entail. each participant must be informed that the participation in the study is voluntary and that he/she may withdraw from the study at any time and that withdrawal of consent will not affect his/her subsequent medical treatment. the participant must be informed that his/her medical records may be examined by authorized individuals other than their treating physician. all participants for this study will be provided a participant information sheet and a consent form describing this study and providing sufficient information for participants to make an informed decision about their participation in this study. the participant information sheet and the consent form will be submitted with the protocol for review and approval for the study by the cec and by swissmedic. the formal consent of a participant, using the approved consent form, must be obtained before that participant is submitted to any study procedure. the participant should read and consider the statement before signing and dating the informed consent form, and should be given a copy of the signed document. the consent form must also be signed and dated by the investigator (or his designee) and it will be retained as part of the study records. the investigator affirms and upholds the principle of the participant's right to privacy and that they shall comply with applicable privacy laws. especially, anonymity of the participants shall be guaranteed when presenting the data at scientific meetings or publishing them in scientific journals. individual subject medical information obtained as a result of this study is considered confidential and disclosure to third parties is prohibited. subject confidentiality will be further ensured by utilising subject identification code numbers to correspond to treatment data in the computer files. such medical information may be given to the participant's personal physician or to other appropriate medical personnel responsible for the participant's welfare, if the patient has given his/her written consent to do so. for data verification purposes, authorised representatives of the sponsor-investigator, a competent authority (e.g. swissmedic), or an ethics committee may require direct access to parts of the medical records relevant to the study, including participants' medical history. the sponsor-investigator may terminate the study prematurely according to certain circumstances, e.g.:  early evidence of benefit or harm of the experimental intervention, e.g. for superiority or futility as defined in statistical methods, (section 10.3);  insufficient participant recruitment, e.g. <30% of the expected number of patients six months after the enrolment of the first patient, also based on the course of sars-cov2 infections in switzerland;  when the safety of the participants is doubtful or at risk, respectively, based on recommendations received from dsmb committee;  changes in accepted clinical practice that make the continuation of a clinical trial unwise, including the results of similar studies or the publication of international guidances. substantial amendments (significant changes) are only implemented after approval of the cec and ca respectively. significant changes to be authorised by the cec are the following:  changes affecting the participants' safety and health, or their rights and obligations;  changes to the protocol, and in particular changes based on new scientific knowledge which concern the trial design, the method of investigation, the endpoints or the form of statistical analysis;  a change of trial site, or conducting the clinical trial at an additional site; or  a change of sponsor, coordinating investigator or investigator responsible at a trial site. significant changes to be authorised by swissmedic are the following:  changes to the therapeutic product, or to its administration or use;  changes based on new preclinical or clinical data which may affect product safety; or  changes concerning the production of the therapeutic product which may affect product safety. under emergency circumstances, deviations from the protocol to protect the rights, safety and well-being of human participants may proceed without prior approval of the sponsor and the cec/ca. such deviations shall be documented and reported to the sponsor and the cec/ca as soon as possible. all non-substantial amendments are communicated to the ca as soon as possible if applicable and to the cec within the annual safety report (asr). coronavirus disease (covid-19) has emerged as a pandemic and a public health crisis of global proportions. as of april 9, 2020, official data on fatality vary across countries due to differences in the age structure of populations, number of screening tests performed, local capacities of healthcare facilities, and criteria used for the compilation of vital certificates reporting the underlying causes of death. comparisons with historical data in some european countries suggest, however, that the mortality may be at least four times higher than what is estimated based on official covid-19 reports, indicating that a substantial number of deaths occurred at home and were not classified as covid-19-related (1). in switzerland, the vast majority of covid-19-related deaths have been recorded in patients aged 50 years or older with age-dependent mortality and hospitalization rates: <0.5% mortality and 9% hospitalization rate between 50-59 years, 2% and 17% between 60 and 69 years, 7% and 30% between 70 and 79 years, and 16% and 30% above 80 years, respectively. one of the most frequently described poor prognostic features in patients with covid-19 is the development of coagulopathy (2) . an increase in d-dimers, which reflects the presence of disseminated intravascular coagulation, is usually observed in the most severe cases of covid-19 and it correlates with in-hospital mortality (2) (3) (4) . in hospitalized patients with sepsis-induced coagulopathy or with markedly elevated d-dimer associated with covid-19 infection, anticoagulation with low-molecular-weight heparin (lmwh) was associated with lower mortality; this association was stronger for higher d-dimer levels: odds ratio for anticoagulation 0.81 (0. 48 although non-survivors with covid-19 had higher d-dimer levels than survivors, d-dimer has not been studied as a potential predictor of death or vte events as it represents an non-specific marker. indeed, the increased levels may reflect acute fibrinous and organising pneumonia characterised by extensive intra-alveolar fibrin deposition (5). its potential use as a surrogate marker of a prothrombotic condition is in its infancy and cannot serve to drive medical decisions i.e. on whether to administer anticoagulation or a higher dosage of antithrombotic prophylaxis. neither the measurement of d-dimers nor the screening with ultrasound are currently recommended in covid-19 outpatients by international guidelines to provide the indication for thrombosis prophylaxis (6) . there are no validated cut-off values for the introduction of d-dimer for risk assessment in covid-19 and the vast majority of covid-19 studies adopted incorrect methodology to build prediction models, also concerning the use of d-dimer (7). in a recent covid-19 consensus paper, it is stated that "elevated d-dimer levels, is a common finding in patients with covid-19, and does not currently warrant routine investigation for acute vte in absence of clinical manifestations or other supporting information."(6) covid-19 emerged as a dramatic prothrombotic condition and it appears now clear, a few months after the first patients described in china, that covid-19 patients are characterized by a substantial risk of developing acute pulmonary embolism (pe) or deep vein thrombosis (dvt) due to local and systemic inflammation, reduced mobility, hypoxia, endothelial dysfunction. during prior viral outbreaks, such as in patients with severe acute respiratory syndrome (sars), myocardial infarction and venous thromboembolism were frequent causes of death (8) . these results emerged from clinical studies and post-mortem examinations (recently reviewed in (9)). small reports on influenza a (h1n1) patients requiring intensive care unit (icu) admission and advanced mechanical ventilation indicated that pe represented a common finding (10) (11) (12) . published, peer-reviewed reports in the biomedical literature have been consistently showing that dvt and, especially, pe represents a key manifestation of covid-19 (13) (14) (15) (16) (17) (18) (19) . we have provided here a brief chronological summary of the most recent evidence that is now growing almost on a daily basis. an analysis of 180 patients admitted at intensive care units in the netherlands showed that thromboembolic events occurred in 16%, of whom the majority had symptomatic vte. pe was the most frequent thrombotic complication (n = 25). age (adjusted hazard ratio (ahr) 1.05/per year, 95%ci 1.004-1.01) and coagulopathy, defined as spontaneous prolongation of the prothrombin time > 3 s or activated partial thromboplastin time > 5 s (ahr 4.1, 95%ci 1.9-9.1), were independent predictors of thrombotic complications (20) . these results suggested that a higher dosage of lmwh thromboprophylaxis may be needed in icu patients due to their extremely high thrombotic risk. in 81 icu patients with covid-19 diagnosed in china, the incidence of vte was 25%: of 20 patients with vte, 8 died (21) . there was no routine screening for vte in this study, whereas the use of thromboprophylaxis was not clearly documented. systematic assessment of vte using complete duplex ultrasound was performed in anticoagulated covid-19 patients admitted to 2 french intensive care units (icu) (17) . the overall rate of vte in patients was 69%. the proportion of vte was significantly higher in patients treated with prophylactic anticoagulation when compared to the other group. in a recent analysis of 388 italian hospitalized patients with covid-19 novel and relevant data emerged. first, a total of 44 (11% of total) patients underwent vte imaging tests and 16 were positive (36% of tests), suggesting substantial underestimation of thromboembolic complications in these patients. second, half of these events were diagnosed on admission, indicating that vte did not develop during hospitalization, but in the ambulatory setting (14) . therefore, the key question would not (only) be whether hospitalized covid-19 patients should receive a higher dosage of lmwh thromboprophylaxis during hospitalization, but if current ambulatory thromboprophylaxis strategies are adequate (22-25). a recent analysis from a french group showed that the rate of thromboembolic complications in 150 covid-19 patients with ards was much higher (11.7%) than what observed in a historical control group of non-covid-19 ards patients (2.1%), despite anticoagulation (26). in a british cohort study of 63 icu patients, the cumulative incidence estimate of vte was 27%. however, only 11 patients received ctpa, of whom 5 were positive for pe (18) . the authors of a french study (27) showed that the cumulative incidence of pe was 20% among icu patients and events occurred after a median of 6 days after hospital admission with 25% of events diagnosed during the first 24 hours. the authors investigated the incidence of objectively confirmed venous thromboembolism (vte) in 198 hospitalized patients with covid-19 in a single-center cohort study. seventy-four patients (37%) were admitted to the intensive care unit (icu). during a median follow-up of 5 days (iqr, 3-9), 33 patients (17%) were diagnosed with vte of whom 22 (11%) had symptomatic vte, despite routine thrombosis prophylaxis. the cumulative incidences of vte at 7 and 14 days were 15% (95% ci, 9.3-22) and 34% (95% ci, 23-46), respectively. vte was associated with death (adjusted hr, 2.9; 95% ci, 1.02-8.0). future research should focus on optimal diagnostic and prophylactic strategies to prevent vte and potentially improve survival. the authors concluded that "future research should focus on optimal diagnostic and prophylactic strategies and assessing the risk of vte in post-discharge and non-hospitalized patients with covid-19." preprint available at: https://www.preprints.org/manuscript/202004.0345/v1. taking this information into account, it is clear that covid-19 represents an unprecedented and highly prothrombotic condition for which current thromboprophylaxis schemes may be inadequate and novel strategies are warranted. only well-conducted randomized controlled trial can provide physicians with useful information to guide clinical decisions. data from the pre-covid-19 era indicate that flu and other seasonal viral infections increase the risk of developing vte in the general population, but do not represent per se an indication to give thromboprophylaxis in the outpatient setting (28) . no large interventional studies have ever been conducted in the outpatient setting to investigate this point. indeed, there are two key differences with the covid-19 outbreak: 1) the vast majority of people aged 60 or older (as well as other "fragile" population subgroups) are routinely vaccinated against influenza, the most feared and prevalent respiratory infection in the elderly. this is obviously not the case for sars-cov2. 2) the burden of viral respiratory infection-associated vte, at least based on indirect data from hospitalized patients, does not appear to be dramatic or extreme as among covid-19 patients. there are further methodological and epidemiological aspects to consider: -the field of viral infection-associated thromboembolism is in its infancy: although up to 7% of unprovoked vte events may be due to viruses, e.g. cytomegalovirus, (29) this patient population has not been object of focused investigations; -there is data from case-control studies informing us about the prevalence of prior (or recent) influenza infection in patients with vs. without acute vte, but evidence on the absolute risk of vte among patients with a respiratory/influenza infection is less firm and usually concerning hospitalized patients (30); -approximately 75% of acute vtes occur in the outpatient setting and acute respiratory infection is one of the highest prevalent risk factor after cancer and recent hospitalization/surgical intervention. it is known from the literature that hospitalized non-icu patients with medical illnesses receiving adequate thromboprophylaxis are characterized by rates that are close to 0% during the first 2 weeks of hospitalization, and indeed not exceeding 3% (31-33). covid-19 patients with chronic coronary artery disease and those with risk factors for atherosclerotic cardiovascular disease have an increased risk to develop myocardial infarction during acute infections, as shown previously in epidemiologic and clinical studies of influenza (34, 35) . acute cardiac injury was reported in 12% of covid-19 cases in a small case series in the lancet. another study suggested a rate of 7.2% among 138 patients from another hospital in wuhan (36). shi et al. and guo et al. showed that patients with myocardial injury had a higher prevalence of hypertension, coronary artery disease, heart failure, and diabetes, as well as more severe inflammation, than those with normal levels of troponin (37, 38) . in china, covid-19 patients with signs of myocardial injury had much higher short-term mortality rates (37, 38) . as with other coronaviruses, sars-cov-2 can elicit the intense release of multiple cytokines and chemokines that can lead not only to vascular inflammation and plaque instability but also to myocardial inflammation (35) . the possibility of direct viral infection of vascular endothelium and myocardium via the host ace-2 receptor has also been raised (39) . the usz was largely involved in the study of the pathophysiology and complications of covid-19 (14, 40) , and identification of key pathophysiological mechanisms: 1) coronavirus binds to the ace-2 respiratory receptor and causes a respiratory infection, 3) coronavirus binds on the ace-2 receptors of the endothelium and penetrates the endothelial cells and causes severe endothelitis in many organs with high amounts of receptors (virus direct detection in the endothelium),(40) 4) coronary virus causes severe endothelitis that we do not see in other viral diseases, 5) «extreme» coagulation activation and coagulopathy, measurable and strongly increased fibrinogen and d-dimers, 6) vte, micro-thrombosis also in other organs, cardiovascular events (2, 6, 14) . a recent isth ssc guidance stated that prophylactic-dose lmwh, such as enoxaparin, should be considered in all patients who require hospital admission for covid-19 in the absence of any contraindications (41). one of the better known non-anticoagulant properties of heparins, their anti-inflammatory function, include binding to inflammatory cytokines, inhibition of neutrophil chemotaxis and leukocyte migration, neutralization of the positively charged peptide complement factor c5a, and sequestering acute phase proteins: this may provide a benefit in covid infection where proinflammatory cytokines are markedly raised and acute respiratory distress syndrome represents a feared and life-threatening complication (41, 42). a paper published in 1992, has also shown that heparin can reduce myocardial inflammation and decrease collagen deposition in an animal model of (chronic) myocarditis (42, 43) , a frequent finding in covid-19 patients. furthermore, in vitro experiments showed that lmwh may be characterized by a protective effect against sars-cov and sars-cov2 viruses, particular limiting the sars-cov1 invasion at the early attachment phase during the initial phase and inhibit virus cell invasion (44) . according to international consensus documents and guidelines, lmwh thromboprophylaxis should be considered in most hospitalized patients with medical illnesses. currently, there is no firm evidence that lmwh thromboprophylaxis should be routinely used in ambulatory medical patients. in switzerland, as in many other european countries, lmwh is approved for thromboprophylaxis in patients with bed rest and acute medical illnesses, such as (i) heart failure, (ii) acute respiratory insufficiency, or (iii) acute infectious or rheumatological conditions in combination, the latter, requiring an additional risk factor or immobilization. a practical guidance for the prevention of thrombosis and management of coagulopathy and disseminated intravascular coagulation of patients infected with covid-19 stated that the risk of vte must be assessed in all patients admitted to hospital, and preventive measures should be taken in all high-risk patients according to international guidelines on thromboprophylaxis in medical patients (nice/ash) (45). several scientific societies, such as the american society of hematology, thrombosis uk, isth, and the gesellschaft für thrombose-und hämostaseforschung (gth), recommend the use of lmwh over new oral anticoagulants for thromboprophylaxis in covid-19 patients in the presence of vte risk factors. of note, bleedings rarely occur in patients with covid-19 (42) . however, the lack of firm evidence prevents the release of more specific recommendations. a recent review on the topic addressed this point (46) with a general statement "while routine use of thromboprophylaxis in outpatients is not recommended, use in immobile infected outpatients, especially with other increased risks for vte, can be considered on a case by case basis based on severity of illness or as incorporated into local practice". taking into accounts all these factors, anticoagulant prophylaxis is being used in the vast majority of covid-19 patients admitted to the hospital as the thromboembolic risk of these patients is perceived to largely exceed that of bleeding. due to the substantial societal burden posed by this outbreak, most western countries developed strategies to handle as many patients as possible on an ambulatory basis. admitted covid-19 patients represent a minority, even among the elderly. ambulatory treatment includes testing, general assessment of the vital parameters, blood withdrawal, and supportive therapy. although there is heterogeneity across regions and countries, quarantine represents the most adopted public health measure to limit viral transmission by isolating patients positive for sars-cov2. it remains unclear whether patients not admitted to the hospital due to non-severe clinical conditions should receive thromboprophylaxis and whether this provides a clinical benefit weighed against the risk of anticoagulant-associated bleeding. the evidence is scarce also for non-covid-19 patients. the most recent american society of hematology (ash) guidelines state that "in medical outpatients with minor provoking risk factors for vte (eg, immobility, minor injury, illness, infection), the ash guideline panel suggests not using vte prophylaxis (conditional recommendation, very low certainty in the evidence of effect)." however, it may be dangerous to extrapolate this low-evidence-level recommendations to patients who may be characterized by a substantial burden of vte due to coagulation activation, local and systemic inflammation, reduced mobility (42) . the following points represent, in summary, the rationale for studying the use of thromboprophylaxis in ambulatory patients with covid-19: 1) the risk of thromboembolic events in patients with covid-19 during anticoagulant prophylaxis exceeds that observed in medical patients, usually <3%, even in the presence of seasonal viral infections (47, 48) 2) the cumulative risk of vte in hospitalized covid-19 patients is at least 20%, but possibly higher, as described in several publications 3) the absolute vte risk in covid-19 patients requiring intensive care is 69% if screening strategies are implemented (17) 4) half of the vte events, mostly pe, were diagnosed at hospital admission, suggesting that these events developed during the quarantine period (14) . our hypothesis is that early thromboprophylaxis may prevent or limit coagulopathy, and reduce thromboembolic complications leading to hospitalization or death, in the presence of a mild covid disease among outpatients. enoxaparin sodium is a low molecular weight heparin marketed under the trade names clexane ® and associated names. this anticoagulant is used in the treatment and prophylaxis of thromboembolic disorders. it is given as an injection subcutaneously or intravenously. the principal pharmacological properties of enoxaparin include antifactor xa and antifactor iia (antithrombin) activity, which are dependent on its binding affinity for antithrombin. clexane ® and associated names solution for injection is currently approved in more than 140 countries worldwide including all the european union (eu) member states as well as switzerland. the first marketing authorisation (ma) was granted in france on 03 april 1987. the product is currently registered in europe under concentrations of 100 mg/ml (equivalent to 10 000 iu anti xa/ml) in prefilled syringes, multi-dose vials, ampoules, and 150 mg/ml (equivalent to 15 000 iu anti xa/ml) in prefilled syringes. vials of 100 mg/10 ml and a pen of 10 x 40 mg (equivalent to 10 x 4 000 iu anti xa) are also authorised. one mg of enoxaparin exhibits 100 iu anti-xa, this allows an easy conversion and representation of the anti-xa activity for the prescriber, and referring to mg instead of biological activity units has been commonly used throughout clinical trials. overall, the general principles of prophylactic and therapeutic indications of enoxaparin are reflected in the pis across europe, however the section was harmonised to address variations in the exact wording in these types of indication, which were different between states. enoxaparin is indicated in adults for: • prophylaxis of venous thromboembolic disease in moderate and high risk surgical patients, in particular those undergoing orthopaedic or general surgery including cancer surgery. • prophylaxis of venous thromboembolic disease in medical patients with reduced mobility and an acute illness (such as acute heart failure, respiratory insufficiency, severe infections or rheumatic diseases at increased risk of venous thromboembolism). • treatment of deep vein thrombosis (dvt) and pulmonary embolism (pe), excluding pe likely to require thrombolytic therapy or surgery. • prevention of thrombus formation in extracorporeal circulation during haemodialysis. • acute coronary syndrome: -treatment of unstable angina and non st-segment elevation myocardial infarction (nstemi), in combination with oral acetylsalicylic acid. -treatment of acute st-segment elevation myocardial infarction (stemi) including patients to be managed medically or with subsequent percutaneous coronary intervention (pci). there are few differences in the various country labels regarding the indication prophylaxis of vte in medical patients. while e.g. the term "bedridden" appears in many countries as a key criteria, some countries have more open definition such as "whose position can be defined at risk" or "temporary immobilised". the accp guidelines recommend: for acutely ill hospitalised medical patients at increased risk of thrombosis, we recommend anticoagulant thromboprophylaxis with lmwh, low-dose unfractionated heparin (lduh) twice a day (bid), lduh three times a day (tid), or fondaparinux: grade 1b. the revised wording is based on the inclusion criteria and the results of the medenox study (31) . the harmonised wording for the indication in this population therefore includes "disease in medical patients with an acute illness (such as acute heart failure, respiratory insufficiency, severe infections or rheumatic diseases) and reduced mobility at increased risk of venous thromboembolism". in switzerland, enoxaparin is approved for the same prophylactic indications. in medical patients with acute illness, the recommended dosage is 40 mg qd s.c. given as a subcutaneous injects for a period of 6-14 days, until complete mobility is not reached. the benefit is not established for a treatment longer than 14 days. from the swiss product monograph (swissmedic-genehmigte fachinformation): «prophylaxe von thromboembolischen erkrankungen venösen ursprungs bei bettlägerigen medizinischen patienten mit einer akuten erkrankung, wie: herzinsuffizienz (nyha klasse iii oder iv); akute respiratorische insuffizienz; akute infektiöse oder rheumatische erkrankungen verbunden mit einem/anderen thromboembolischen risikofaktor/en.» in acutely ill medical patients, the american society of hematology (ash) guideline panel suggests using unfractionated heparin, lmwh, or fondaparinux rather than no parenteral anticoagulant (conditional recommendation, low certainty in the evidence of effects). among these anticoagulants, the panel suggests using lmwh (low certainty in the evidence of effects) or fondaparinux (very low certainty in the evidence of effects) rather than ufh (conditional recommendation). besides the anticoagulant effects of enoxaparin sodium, there was no evidence of adverse effects at 15 mg/kg/day in the 13-week sc toxicity studies both in rats and dogs and at 10 mg/kg/day in the 26-week sc and iv toxicity studies both in rats, and monkeys. enoxaparin sodium has shown no mutagenic activity based on in vitro tests, including the ames test, mouse lymphoma cell forward mutation test, and no clastogenic activity based on an in vitro human lymphocyte chromosomal aberration test, and the in vivo rat bone marrow chromosomal aberration test. studies conducted in pregnant rats and rabbits at sc doses of enoxaparin sodium up to 30 mg/kg/day did not reveal any evidence of teratogenic effects or foetotoxicity. enoxaparin sodium was found to have no effect on fertility or reproductive performance of male and female rats at sc doses up to 20 mg/kg/day. enoxaparin has been used for more than 20 years and represented the reference treatment for the large majority of phase iii trials studying direct oral anticoagulants (rivaroxaban, dabigatran etexilate, apixaban, edoxaban) for the prevention of vte in medical (49) and surgical orthopaedic patients (50) and for the acute treatment of vte (51), including cancer-associated vte (52) and pregnancy-associated vte (53) . it remains one of the treatments of choice for these indications (54-57). the proposed dose, 40 mg/day, and treatment duration (14 days) is in line with the product label, which are primarily based on the results from the medenox study (58) where this was effective, as opposed to the 20 mg/day dose that was not. the medenox study evaluated enoxaparin at both 2000 ui and 4000 ui. only enoxaparin at 4000 ui demonstrated the efficacy for the prevention of vte in medical patients. in addition, the mean duration of treatment is 10 days, up to 14 days in the medenox study. the harmonised treatment duration is aligned with the data from the medenox study (6 to 14 days), as there is no evidence that a shorter duration may be effective (58). risk assessment models (i.e. the padua and the improve scores) are used to identify patients who should receive in-hospital thromboprophylaxis based on a risk benefit assessment according with international guidelines (57) . enoxaparin may be used in ambulatory patients with acute infectious illness, if an additional vte risk factor is present. therefore, no treatment represents the current standard of care for the covid (+) patients without additional vte risk factor. published data and studies under review (co-authors are the ovid investigators) suggest that (i) covid-19 is highly prothrombotic, (ii) a significant number of vte events occur in ambulatory patients and is detected at the time of initial evaluation. therefore, higherdosage thromboprophylaxis has been postulated for admitted patients and routine thromboprophylaxis may be useful for ambulatory patients in order to prevent potential thromboembolic complications before the patients´ general conditions precipitate. enoxaparin is effective in preventing vte in medical patients with acute illness. its antiinflammatory and antithrombotic profile may be highly beneficial in the setting of covid-19. initial report in admitted covid-19 patients shows that lmwh appears to be beneficial in the presence of coagulation activation (4). the ambulatory administration of injectable anticoagulants, including lmwh and the pentasaccharide fondaparinux, has been and is standard of care for a number of clinical conditions, including thromboprophylaxis after major orthopedic surgery and, especially in the era preceding the approval of direct oral anticoagulants, also the treatment of acute vte. indeed, the initial use of lmwh remains standard of care for patients, especially the elderly, with contraindications to the use of direct oral anticoagulants. in this setting, patient instructions are usually given during the initial in-hospital visit, corresponding to the day of hospital discharge after orthopedic surgery or the day of acute vte diagnosis; subsequently, patients self-administer the prefilled anticoagulant injections, alone or with the help of family members, in the ambulatory setting and, depending on the indication, for a period of 10-35 days (i.e. 35 days after hip arthroplasty, 14 days after knee arthroplasty). of note, 6-month (ambulatory) therapy with subcutaneous lmwh still represents the therapy of choice of the treatment of acute vte among several groups of cancer patients (59) . in-hospital follow-up visits after the start of prophylactic-dose anticoagulant administration were not part of the study procedures of recent orthopedic trials on thromboprophylaxis, which usually included early phone follow-up intermediate to verify compliance and the potential occurrence of adverse events (60, 61) . enoxaparin is characterized by a high safety profile and has been used for multiple indications for over 20 years. a recent meta-analysis of thromboprophylaxis trials in medically ill patients showed that a major bleeding event occurred in 157 of 26608 (0.6%) of patients during short-course administration (14 days of lower). the two largest and most recent phase iii trials on extended thromboprophylaxis in medically ill patients, the magellan and mariner study, had major bleeding rates of 0.3% and 0.2%, respectively (32, 62) . it must be further noted that approximately 1% of the general population receive therapeutic-dose anticoagulant treatment for the prevention of embolic events due to atrial fibrillation or for the treatment of vte. this prevalence of anticoagulant users exceeds 3-5% among the elderly. anticoagulant treatment is one of the best-known medical therapies used in western countries and the management of potential complications is part of routine clinical practice. the risk of heparin-induced thrombocytopenia in lmwh-treated patients is negligible (0.8%) and of those who develop heparin-induced thrombocytopenia only a minority would develop a thromboembolic event (30% of 0.8% = 0.024% of patients receiving lmwh) (63) . as reported in section 8.1.1. enoxaparin does not accumulate in the body after multiple administrations in the absence of severe renal dysfunction, one of the key exclusion criteria of the ovid study. moreover, the study will include only patients in whom the self-administration of enoxaparin (or the administration by a person living in the same house) after instructions is deemed possible (see inclusion criteria). this is in line with current practice, e.g. after orthopaedic surgery or in cancer patients with acute vte. currently, in switzerland there is no specific follow-up strategy for patients who are tested positive for sars-cov2 and are candidates to an ambulatory treatment. the current standard of care for outpatient covid treatment at some centers is as follows: 1) patient goes to the test center with symptoms; 2) the physician performs a sars-cov2 test and triage the patient concerning potential hospitalization. this may include standard assessment of the presence of dvt or pe, if deemed necessary. if not, the patient is discharged to home quarantine without taking blood and without performing any laboratory diagnostics. 3) there is no direct contact with doctors and care in the home quarantine in order not to endanger personnel. ovid may increase the level of safety compared to standard of care for study patients because frequent telephone visits are planned (day 3, 7, 14, 30, 90) . this regards also patients who are not randomized to the intervention arm. this approach is now becoming standard of care at some covid-19 centers: however, this is not uniform across the country and the planned contacts are less frequent than in the ovid study. thus, being part of a clinical study with predefined phone contacts will allow the patient to be constantly followed by medical and study personnel. the standardized visit questionnaire ensures that relevant bleeding is not missed. there is substantial uncertainty regarding the routine use of thromboprophylaxis for covid-19 in the outpatient setting. as previously discussed, recommendations are based on expert consensus and are largely adapted on local protocols. the present study hypothesizes a potential benefit of thromboprophylaxis, which could reduce the number of hospitalizations (primarily due to thromboembolic complications) and the number of deaths among enoxaparin-treated patients. the thromboembolic manifestations of covid-19 have been object of extensive media coverage. therefore, we anticipate that patients may be worried of being randomized to the control group and not receiving anticoagulant prophylaxis. the investigators will make clear during the patient consent procedure that (i) the potential benefits of thromboprophylaxis have not been demonstrated yet, (ii) the use of enoxaparin is characterized by a low (and well-quantifiable from prior studies) risk of major bleeding, <1% within 2 weeks of treatment, (iii) the risk benefit balance should be objective of investigation in the context of a phase iii trial, as there is no current evidence supporting the routine use of thromboprophylaxis. the study population was selected based on the following reasons: -covid-19-patients 50 years or older are those characterized by the highest hospitalization and fatality rates and, therefore, those who may benefit most from a prophylactic therapy with enoxaparinwe will include only symptomatic patients who presented with fever or respiratory symptoms, therefore aiming to minimize the number of incidental positive tests done for screening reasons.patients at the highest risk of vte, including patients with cancer or with prior vte, will be excluded as it would not be appropriate to include those, as the authors believe that they should routinely receive ambulatory thromboprophylaxis. -at the same time, patients characterized by a high bleeding risk will be excluded, including those with intracranial malignancy, recent bleeding, or strong dual antiplatelet therapy. -recent data suggest that several vte and deaths are recorded during "secondary" hospitalization which followed a diagnosis of covid-19 and an initial ambulatory treatment. -the almost totality of covid-19 trials is currently focusing on hospitalized patients: therefore, our study will not be competing with other studies for enrolment; -of note, patient with an initial suspicion of symptomatic vte (i.e. upon sars-cov2 testing) will and should undergo standard assessment by vte imaging and, in the case that vte is confirmed, the patient cannot be considered eligible for inclusion in the ovid study. the screening strategies upon sars-cov2 testing are left at the discretion of the treating physicians as at the moment there is no evidence that those should be implemented. the ovid study will show whether enoxaparin improves survival and reduces hospitalization in ambulatory patients aged 50 or older diagnosed with covid-19, a novel viral disease characterized by severe systemic, pulmonary, and vessel inflammation and coagulation activation. the purpose of this study is to show the superiority of ambulatory thromboprophylaxis with enoxaparin versus no treatment to prevent any hospitalization and all-cause death within 30 days of randomization in patients aged 50 or older with covid-19. key secondary objectives for this study are to determine if enoxaparin administration versus no treatment reduces specific cardiovascular and thromboembolic complications, namely venous thromboembolism, myocardial infarction or stroke, within 14 days, 30 days and 90 days of randomization, and if this intervention is associated with a net clinical benefit, accounting for major bleeding events. subgroup analysis to study treatment effects of enoxaparin (versus no treatment) will be conducted in specific subgroups of patients categorized by sex, age (50-70 vs. >70 years), renal function (estimated renal function <50 ml/min vs. 50 ml/min or higher), and concomitant antiplatelet therapy. the study will assess the safety of thromboprophylaxis in covid-19 ambulatory patients aged 50 or older and quantify the risk of major bleeding, non-major clinically relevant bleeding, and adverse events. a composite of any hospitalization or all-cause death occurring within 30 days of randomization. composite outcome of cardiovascular events, including deep vein thrombosis (including catheter-associated), pulmonary embolism, myocardial infarction/myocarditis, arterial ischemia including mesenteric and extremities, acute splanchnic vein thrombosis, or ischemic stroke within 14 days, 30 days, and 90 days of randomization 1) each component of the primary efficacy outcome, within 14 days, 30 days, and 90 days of randomization. net clinical benefit (accounting for the primary efficacy outcome, composite cardiovascular events, and major bleeding), within 14 days, 30 days, and 90 days of enrolment. primary efficacy outcome, within 14 days, and 90 days of enrolment. disseminated intravascular coagulation (isth criteria, in-hospital diagnosis) within 14 days, 30 days, and 90 days of enrolment. important cardiovascular events have been listed as secondary outcomes as we anticipate that appropriate imaging tests may be underused in this population, leading to an underestimation of these rates in both groups. in light of the above, information on secondary outcomes will be retrieved from medically certified discharge letters and ambulatory/laboratory reports, therefore not requiring formal event adjudication. not applicable. the principal safety outcome is major bleeding, defined as overt bleeding associated with a decrease in the hemoglobin level of 2 g/dl (1.24 mmol l −1 ) or more, bleeding that led to transfusion of 2 or more units of packed red cells or whole blood, bleeding that occurred in a critical site (i.e., intracranial, intraspinal, intraocular, pericardial, intraarticular, intramuscular with compartment syndrome, or retroperitoneal), or fatal bleeding (isth criterion) (64) . the other safety outcome is non-major clinically relevant bleeding and adverse events. non-major clinically relevant bleeding is defined as overt bleeding that did not meet the criteria for major bleeding but was associated with medical intervention, unscheduled contact (visit or telephone call) with a physician, temporary cessation of the trial regimen, or pain or impairment of activities of daily life (isth criterion) (64) . all serious adverse events potentially related to the study medication (i.e. local and systemic bleeding complications, allergic reactions) and reasons for hospitalizations except the study outcomes (vte-related death, myocardial infarction, stroke, symptomatic vte [dvt and pe], bleeding events) will be collected. the study will be conducted as a multicentre randomized open-label controlled trial. in the study, a total of 1,000 adult patients aged 50 or older with symptomatic covid-19, without other indications to anticoagulant therapy, and candidates to ambulatory treatment will be randomized to receive enoxaparin 40 mg sc qd or no treatment for a total of 14 days. the primary outcome is any hospitalization or all-cause death within 30 days of enrolment. a final 90-day phone contact is planned. patient enrolment will last up to 6 months and will take place at 7 swiss centers, including five university hospitals and two large cantonal hospitals. the study period will therefore consist of a total of approximately 10 months. patients will undergo block stratified randomization (by age 50-70 vs. >70 years and study center) with a randomization ratio of 1:1 with block sizes varying between 4 and 8. no blinding procedures will be used in this study for logistical reasons. predefined questionnaires will serve to guide telephonic contacts with patients during (pre-)screening and follow-up visits. the adoption of objective study efficacy outcomes (any hospitalizations, all-cause death) aims at minimizing the risk of subjective interpretation. not applicable. an average of 140 patients will be enrolled at each of the 7 study centers, represented by all the university swiss hospitals and two large cantonal hospitals. it is expected that patients will be enrolled over 6-7 months, corresponding to an average of approximately one patient per day per center. in case the enrolment goals are not met after the first 3 months from study start, the participation of additional centers will be considered, as well as the extension to other european countries upon positive application for public funding. and eligible for ambulatory treatment. 3) presence of respiratory symptoms (i.e. cough, sore throat, or shortness of breath) or body temperature >37.5° c. 4) ability of the patient to travel to the study center by private transportation, performed either by accompanying person from same household or by the patient him/herself 5) ability to comply with standard hygiene requirements at the time of in-hospital visit, including a face mask and hand disinfectant. 6) ability to walk from car to study center or reach it using a wheel chair transport with the help of an accompanying person from the same household also complying with standard hygiene requirements. 7) ability to self-administer prefilled enoxaparin injections after instructions received at the study center or availability of a person living with the patient to administer enoxaparin. the presence of any one of the following exclusion criteria will lead to exclusion of the participant: 1) any acute or chronic condition posing an indication for anticoagulant treatment, e.g. atrial fibrillation, prior vte, acute confirmed symptomatic vte, acute coronary syndrome. 2) anticoagulant thromboprophylaxis deemed necessary in view of the patient's history, comorbidity or predisposing strong risk factors for thrombosis: a. any of the following events occurring in the prior 30 days: fracture of lower limb, hospitalization for heart failure, hip/knee replacement, major trauma, spinal cord injury, stroke, b. previous vte, c. histologically confirmed malignancy, which was diagnosed or treated (surgery, chemotherapy, radiotherapy) in the past 6 months, or recurrent, or metastatic, or inoperable. 3) any clinically relevant bleeding (defined as bleeding requiring hospitalization, transfusion, surgical intervention, invasive procedures, occurring in a critical anatomical site, or causing disability) within 30 days prior to randomization or sign of acute bleeding. 4) intracerebral bleeding at any time in the past or signs/symptoms consistent with acute intracranial hemorrhage. 5) hemoglobin <8 g/dl and platelet count <50 x 10 9 cells/l confirmed by recent laboratory test (<90 days). 6) subjects with any known coagulopathy or bleeding diathesis, including known significant liver disease associated with coagulopathy. 7) severe renal insufficiency (baseline creatinine clearance <30 ml/min calculated using the cockcroft-gault formula) confirmed by recent laboratory test (<90 days). 8) contraindications to enoxaparin therapy, including prior heparin-induced thrombocytopenia and known hypersensitivity. 9) current use of dual antiplatelet therapy. 10) participation in other interventional studies over the past 30 days. 11) non-compliance or inability to adhere to treatment or lack of a family environment or support system for home treatment. 12) cognitive impairment and/or inability to understand to information provided in the study information. we considered three main screening scenarios preceding the in-hospital baseline visit: -scenario 1: screening at the study center on the day of sars-cov2 testing -scenario 2: referral from the patient (via hot-line or study center). -scenario 3: referral from covid testing centers or primary care physicians (via hot-line or study center). scenario 1: enrolment at the study center on the day of sars-cov2 testing 1) test for sars-cov2: i.e. at the emergency room or at covid testing center at the study site. 2) the patient waits for the results of sars-cov2 (i.e. done with rapid tests) at the same center, as per local standard practice in a deputed room. 3) discussion with the study investigator, signature of pic2, evaluation of the eligibility criteria. if not available, additional blood tests (blood cell counts, renal function) will be performed as part of the study screening using standard measurement or point of care devices. 4) details on randomization, allocation, and instructions are given in the next paragraph ("in-hospital visit"). scenario 2: referral from the patient. 1) the patient undergoes sars-cov2 test and gets to know about the ovid study (flyer). 2) the patient goes home and waits for the test results being communicated by the test center. 3) the patient is informed by the testing center about his/her positive sars-cov2 test. 4) he/she phones the trilingual hot-line or directly the referral study center and the potential study participation is evaluated first, particularly concerning the formal ovid eligibility criteria (see pre-screen questionnaire for hot-line and study centers). 5) if the patient is potentially eligible, the hot-line personnel or the study center plans a further in-hospital visit at the closest study center within 5 days from positive sars-cov2 test. 6) see the paragraph "in-hospital visit" for further details. scenario 3: referral from covid testing centers or primary care physicians. 1) the patient undergoes sars-cov2 test and gets to know about the ovid study (flyer and pic1) and potential eligibility. 2) the patient allows the test center personnel to inform the study physicians about (i) his/her positive test and (ii) his/her contact information (signature of pic1). 3) the patient goes home and waits for the test results being communicated by the test center. 4) the test center informs the hot-line or study center about (i) patient's positive test and (ii) his/her personal information. 5) the hot-line or study center phones the patient and the potential study participation is further evaluated, particularly concerning the formal ovid eligibility criteria (see prescreen questionnaire). 6) if the patient is potentially eligible, the hot-line personnel of the study center plans a further in-hospital visit at the closest study center within 5 days from positive sars-cov2 test 7) see the paragraph "in-hospital visit" for further details. patient recruitment will be centrally organised and coordinated also with the aid of a national hot-line in three languages (german, french, italian), ensuring a one-time contact with patients to preliminary verify the eligibility criteria and plan an in-hospital visit for screening and recruitment. the hot-line number will be published on official websites and will be made available as part of an awareness campaign organized by the communication department of the usz. deputed personnel receiving following precise instructions given by the study investigators will be available during working hours to discuss with patients. a predefined pre-screening questionnaire will be completed telephonically following a step-by-step standardized procedure. if the patient is not eligible, i.e. one red box is checked in the questionnaire, the questionnaire will be destroyed immediately after compilation by the hot-line personnel and no personal data will be registered. if the patient is potentially eligible, a study visit will be planned from the hot-line at the closest study center or the study center will be contacted directly by the patient. the hot-line will provide the study investigators at each study center with a copy of the questionnaire containing prescreening information. the study site is then asked to complete the questionnaire with the data and time of the in-hospital visit and return the questionnaire to the study e-mail address: ovidstudie@usz.ch. trained staff for the hot-line may include physicians, nurses, medical students, and administrative personell, who is also educated to encourage the patient (i) to bring any medical documents to the in-hospital visit that may facilitate enrolment, e.g. medication lists or medical reports or the results of recent laboratory testing and if applicable a copy of the signed pic 1. in addition the hot-line personnel will provide the study information and consent form (pic 2) by email if desired by the patient. the hot-line personnel instructs the patient to come by private car, use the reserved parking spaces and stay in the car until he/she gets further instructions from the study personnel. information concerning the precise location of the parking place at each study center will be given telephonically to the patients and may be sent via e-mail upon patient's request by local study personnel. 1. the study personal reaches the car of the patient and provides him/her and if applicable his/her companion with face masks and desinfectant. the patient will then follow the study coordinator to the assigned study rooms. if the patient is dependent on a wheel chair, he/she must be able to transfer him/herself or with the aid of the companion into the wheel char. the accompanying person is only allowed to enter the study rooms and attend the study visit, if he/she is determined to apply the clexane injections. in this case, the accompanying person gets the clexane administration instruction. 2. the study physician will discuss the scope of the study and answers all questions of the patient. is the patient willing to participate in the study, he/she will sign the pic 2. after signature of pic2, a further check of inclusion and exclusion criteria will be performed by the treating physician, using if available medical documents. a blood test will be performed, if no blood test results are available. during blood analysis, the other parameters for the screening visit can be collected, e.g. vital signs, demographics, etc. (see paragraph study assessment). 3. if the blood test is in line with the inclusion and exclusion criteria, the study physician performs the final check of the eligibility. if eligibility cannot definitively be confirmed, no randomization will be performed and the patient will be counted as screening failure. 4. if eligibility is confirmed, randomization will be done. the patient receives a study participant card, where the contact data from the study team are reported and information on study drug allocation. 5. for patients from the control group, patient will return home by private car transport. for patients form the enoxaparin group, instruction for use of enoxaparin injections will be provided. for interested patients, a link for a video instruction will be provided. the first injection of study drug will be performed at study center, if possible by the patient. if patient does not inject the study drug, the accompanying person gets the instruction and will perform the first injection. 6. for patients of the treatment group, the required amount of study drug will be provided to the patients with instructions for documentation. the patients are encouraged to fill in the study diary, which is provided by the study team and will be instructed to take note of doses that are forgotten or missed. this form will be handed to the patients with a pre-stamped reply covert to simplify the return process. the study visit is planned for at least 60 minutes for all patients who received the ovid patient information by email in advance. the study visit is planned for at least 90 minutes for all patients who did not receive the ovid patient information by email in advance to provide enough time for considering study participation. only one in-hospital visit is planned. as previously described, the best care will be taken to minimize the discomfort for the patient and maximize safety for the investigators. to reduce the infection risk, only a study physician will be in the study room with the patient. if needed, the blood test (hemoglobin, platelet count, creatinine) may be performed by the use of a point-of-care device, which guarantees a result within minutes and the study physician will be informed about the results immediately. all the participating centers agreed to fulfil these logistic requirements and will be able to guarantee the same standard of care by signing a contract. these requirements were part of the criteria for the selection of the study sites. definition: all patients who signed the informed consent 2 (pic2) but were not eligible for randomization. a screening log will be filled out at each study center, listing all patients with date and reason of screening failure. this document will be signed by the local principal investigator at the end of the recruitment period and returned to the sponsor. these recruitment and study procedures have been object of a survey among 15 general patients aged 50 years or older recruited through a patient organization conducted between 11-13 april 2020, who confirmed that what we propose is in line with their expectations. in particular, 91% stated that they feel able to reach a covid-19 testing site without public transportation, 63% would be willing to read an information sheet on location regarding possible inclusion in a clinical study whilst waiting to have the test sample taken, , 75% would agree to receive a paper copy of the informed consent at home (delivered by postal mail), 86% would travel to the local center/hospital to obtain study medication after receiving notice of a positive covid-19 test, 100% would accept to receive courier delivery of study medication at home. randomization will be performed after the signature of the informed consent for participation and the verification of the eligibility criteria. randomization will be performed by an instructed assistant, study coordinator, or investigator directly through the electronic data capture software (redcap, vanderbilt university, v9.1.24). additional details concerning the setting and timing of randomization are provided in the study procedures. if the subject permanently discontinues treatment before day 14 or is hospitalized, then he/she needs to have the remaining scheduled visits. because the primary efficacy analysis of the study is based upon the intention-to treat principle, the subject will be contacted for the remaining scheduled visits. if the subject cannot be contacted telephonically, the site should collect as much follow-up information as possible, including contacting a legally acceptable representative or the treating physician by telephone or by mail to determine vital status and if a hospitalization has occurred. vital status will be obtained by reviewing the subject's medical or public records or discharge letters from other institutions, as reported in the patient information. if the subject withdraws consent from the study, this must be documented in the source document and the subject will be asked to supplement the withdrawal of consent with a signed written statement documenting refusal sent per post for all subsequent contact. if the patient does not wish to send a written statement, study withdrawal will take place immediately after giving verbal notification. enoxaparin is a lmwh with a mean molecular weight of approximately 4,500 daltons, in which the antithrombotic and anticoagulant activities of standard heparin have been dissociated. the drug substance is the sodium salt. in the in vitro purified system, enoxaparin sodium has a high anti-xa activity (approximately 100 iu/mg) and low anti-iia or anti thrombin activity (approximately 28 iu/mg), with a ratio of 3.6. these anticoagulant activities are mediated through anti-thrombin iii (atiii) resulting in anti-thrombotic activities in humans. beyond its anti-xa/iia activity, further antithrombotic and antiinflammatory properties of enoxaparin have been identified in healthy subjects and patients as well as in non-clinical models. these include atiii-dependent inhibition of other coagulation factors like factor viia, induction of endogenous tissue factor pathway inhibitor (tfpi) release as well as a reduced release of von willebrand factor (vwf) from the vascular endothelium into the blood circulation. these factors are known to contribute to the overall antithrombotic effect of enoxaparin sodium. when used as prophylactic treatment, enoxaparin sodium does not significantly affect the aptt. when used as curative treatment, aptt can be prolonged by 1.5-2.2 times the control time at peak activity. the pharmacokinetic parameters of enoxaparin sodium have been studied primarily in terms of the time course of plasma anti-xa activity and also by anti-iia activity, at the recommended dosage ranges after single and repeated sc administration and after single iv administration. the quantitative determination of anti-xa and anti-iia pharmacokinetic activities was conducted by validated amidolytic methods. absorption the absolute bioavailability of enoxaparin sodium after sc injection, based on anti-xa activity, is close to 100%. different doses and formulations and dosing regimens can be used. the mean maximum plasma anti-xa activity level is observed 3 to 5 hours after sc injection and achieves approximately 0.2, 0.4, 1.0 and 1.3 anti-xa iu/ml following single sc administration of 2,000 iu, 4,000 iu, 100 iu/kg and 150 iu/kg (20 mg, 40 mg, 1 mg/kg and 1.5 mg/kg) doses, respectively. a 3,000 iu (30 mg) iv bolus immediately followed by a 100 iu/kg (1 mg/kg) sc every 12 hours provided initial maximum anti-xa activity level of 1.16 iu/ml (n=16) and average exposure corresponding to 88% of steady-state levels. steady-state is achieved on the second day of treatment. after repeated sc administration of 4,000 iu (40 mg) once daily and 150 iu/kg (1.5 mg/kg) once daily regimens in healthy volunteers, the steady-state is reached on day 2 with an average exposure ratio about 15% higher than after a single dose. after repeated sc administration of the 100 iu/kg (1 mg/kg) twice daily regimen, the steady-state is reached from day 3 to 4 with mean exposure about 65% higher than after a single dose and mean maximum and trough anti-xa activity levels of about 1.2 and 0.52 iu/ml, respectively. injection volume and dose concentration over the range 100-200 mg/ml does not affect pharmacokinetic parameters in healthy volunteers. enoxaparin sodium pharmacokinetics appears to be linear over the recommended dosage ranges. intra-patient and inter-patient variability is low. following repeated sc administration, no accumulation takes place. plasma anti-iia activity after sc administration is approximately ten-fold lower than anti-xa activity. the mean maximum anti-iia activity level is observed approximately 3 to 4 hours following sc injection and reaches 0.13 iu/ml and 0.19 iu/ml following repeated administration of 100 iu/kg (1 mg/kg) twice daily and 150 iu/kg (1.5 mg/kg) once daily, respectively. the volume of distribution of enoxaparin sodium anti-xa activity is about 4.3 litres and is close to the blood volume. enoxaparin sodium is primarily metabolized in the liver by desulfation and/or depolymerization to lower molecular weight species with much reduced biological potency. enoxaparin sodium is a low clearance drug with a mean anti-xa plasma clearance of 0.74 l/h after a 150 iu /kg (1.5 mg/kg) 6-hour iv infusion. elimination appears monophasic with a half-life of about 5 hours after a single sc dose to about 7 hours after repeated dosing. renal clearance of active fragments represents about 10% of the administered dose and total renal excretion of active and non-active fragments 40% of the dose. special populations based on the results of a population pharmacokinetic analysis, the enoxaparin sodium kinetic profile is not different in elderly subjects compared to younger subjects when renal function is normal. however, since renal function is known to decline with age, elderly patients may show reduced elimination of enoxaparin sodium (see sections 4.2 and 4.4). hepatic impairment in a study conducted in patients with advanced cirrhosis treated with enoxaparin sodium 4,000 iu (40 mg) once daily, a decrease in maximum anti-xa activity was associated with an increase in the severity of hepatic impairment (assessed by child-pugh categories). this decrease was mainly attributed to a decrease in atiii level secondary to a reduced synthesis of atiii in patients with hepatic impairment. a linear relationship between anti-xa plasma clearance and creatinine clearance at steady-state has been observed, which indicates decreased clearance of enoxaparin sodium in patients with reduced renal function. anti-xa exposure represented by auc, at steady-state, is marginally increased in mild (creatinine clearance 50-80 ml/min) and moderate (creatinine clearance 30-50 ml/min) renal impairment after repeated sc 4,000 iu (40 mg) once daily doses. in patients with severe renal impairment (creatinine clearance <30 ml/min), the auc at steady state is significantly increased on average by 65% after repeated sc 4,000 iu (40 mg) once daily doses (see sections 4.2 and 4.4). enoxaparin sodium pharmacokinetics appeared similar than control population, after a single 25 iu, 50 iu or 100 iu/kg (0.25, 0.50 or 1.0 mg/kg) iv dose however, auc was two-fold higher than control. after repeated sc 150 iu/kg (1.5 mg/kg) once daily dosing, mean auc of anti-xa activity is marginally higher at steady state in obese healthy volunteers (bmi 30-48 kg/m2) compared to non-obese control subjects, while maximum plasma anti-xa activity level is not increased. there is a lower weight-adjusted clearance in obese subjects with sc dosing. when non-weight adjusted dosing was administered, it was found after a single-sc 4,000 iu (40 mg) dose, that anti-xa exposure is 52% higher in low-weight women (<45 kg) and 27% higher in low-weight men (<57 kg) when compared to normal weight control subjects (see section 4.4). no pharmacokinetic interactions were observed between enoxaparin sodium and thrombolytics when administered concomitantly. water for injections. shelf life 2 years. clexane ® forte syringes 12,000 iu (120 mg)/0.8 ml and 15,000 iu (150mg)/1 ml: solution for injection in graduated pre-filled syringes (type i glass) fitted with rubber stopper (chlorobutyl and bromobuytl) and injection needle (with automatic safety system eristm or preventis™ or without an automatic safety system). supplied in packs of 2, 5, 6, 10, 20, 30, 50 pre-filled syringes and in multi-packs of 3 x 10 pre-filled syringes. not all pack sizes may be marketed. pre-filled syringes are ready for immediate use. for method of administration see section 4.2. use only clear, colourless to yellowish solutions. pre-filled syringes are supplied with or without an automatic safety system. the instructions for use are presented in the package leaflet. each syringe is for single use only. used syringes will be discarded into regular trash without trying to recap the already automatically retracted needle. any unused medicinal product (enoxaparin prefilled injections) should be returned back to the study center at a later timepoint (>5 days) due to potential contamination. no treatment. the sponsor will label the study medication centrally and ship an initial amount of the study medication to the participating centers, which should be sufficient for the enrolment of the first 80 patients per center and will consist of 10-and 2-syrynge packages. the shipment will be performed in accordance with storage requirements (see below). upon receipt of the study treatment supplies, an inventory must be performed and a drug receipt log filled out and signed by the person accepting the shipment. it is important that the designated study staff counts and verifies that the shipment contains all the items noted in the shipment inventory. any damaged or unusable study drug in a given shipment will be documented in the study files and the sponsor will be notified by the study-site personnel within 24 hours after being aware of the event. the investigator is responsible for ensuring that all study drug received at the site is inventoried and accounted for throughout the study. the dispensing of study drug to the subject must be documented on the drug accountability form, signed and dated by the study team. do not store above 25°c. do not freeze. enoxaparin (clexane ® ) will be given at the recommended dose of 4,000 iu antixa activity (40 mg)/0.4 ml once daily by sc injection for 14 days. the first dose of enoxaparin will be administered on the day of randomization. the subsequent doses of enoxaparin will be administered or self-administered at home. instructions on how to administer enoxaparin will be provided during the screening/baseline visit. additional details are reported in the study procedures. solution for injection in pre-filled syringes. clear, colourless to yellowish solution, phvalue 5.5-7.5. enoxaparin should not be administered by the intramuscular route. for the prophylaxis of venous thromboembolic disease following surgery, treatment of dvt and pe, treatment of unstable angina and nstemi, enoxaparin sodium should be administered by sc injection. the pre-filled disposable syringe is ready for immediate use. sc injection technique: injection should be made preferably when the patient is lying down. enoxaparin sodium is administered by deep sc injection. do not expel the air bubble from the syringe before the injection to avoid the loss of drug when using pre-filled syringes. the administration should be alternated between the left and right anterolateral or posterolateral abdominal wall, and upper legs. not applicable. in accordance with the label of enoxaparin, no dose modification is requested. in case of hospitalization (component of the primary efficacy outcome) or bleeding (secondary outcome) or any other adverse event that may occur, the dose can be modified based on what decided by the treating physician, as per standard clinical practice. this will not influence the primary efficacy outcome analysis, which will be conducted on a intention-to-treat basis. the study team will assess and track participant compliance during the scheduled phone follow-up visits (day 3, 7 and day 14) and according with a pre-defined questionnaire evaluating the use of the study medication and potentially related adverse events. if a patient withdraws from the study, data until the date of withdrawal will be used for analysis. if a subject has a serious bleeding event during study drug treatment, the following routine measures should be considered: -delay the next study drug administration, or discontinue treatment if indicated. temporary cessation of study drug may allow control of bleeding. consider the usual treatment measures for bleeding events, including fluid replacement and hemodynamic support, blood transfusion, and fresh frozen plasma, if physical examination and laboratory testing suggest benefit could be obtained. in case of life-threatening bleeding occurring during enoxaparin administration, protamine may be used for reversal, as per standard management, although it is known that it only partially reverses the anti-xa activity and there are very limited data on clinical effectiveness. if deemed necessary, enoxaparin reversal can be determined based on the following table (lovenox [package insert]. sanofi-aventis u.s. llc; bridgewater, nj. october 2013): ≤ 8 hours since heparin dose: 1 mg protamine for every 1 mg enoxaparin; > 8 hours since heparin dose: 0.5 mg protamine for every 1 mg enoxaparin; > 12 to 24 hours since heparin dose: depending on dose received and renal function, protamine reversal may not be necessary due to enoxaparin metabolism. all concomitant and/or rescue treatment(s) have to be recorded in the ecrf. the use of other anticoagulant agents is not recommended during the study period, as it may significantly increase the risk of bleeding. if another anticoagulant agent is deemed necessary (i.e. for a new diagnosis of atrial fibrillation), the switching from enoxaparin to the new anticoagulant agent will be performed according with standard procedures. paracetamol should be considered the drug of choice to treat fever or pain. the use of ibuprofen (or other nsaids) is not forbidden, although its administration should be discussed with the treating or study physician. similarly, the introduction of an antiplatelet therapy should be discussed with the treating physicians and principally be avoided in the absence of a major (e.g. cardiologic) indication. investigational product supplies, which will be provided to the principal investigator of each site, must be kept in a secure, limited access storage area under the recommended storage conditions. lot number and expiry date should be listed. the investigator will maintain accurate and adequate records including dates, lot number, quantities received, usage. in addition, a study diary will be handed to patients in the treatment group and patients will be encouraged to document forgotten or missed doses (as described in 7.2). a missed injection can be made up for up to 6 hours, not used study products should be returned to the site. the used study product will not be collected, but disposed through the regular household waste. at the completion of the study, there will be a final reconciliation of drug shipped, drug consumed, and drug remaining. this reconciliation will be logged on the drug accountability form, signed and dated. any discrepancies noted will be investigated, resolved, and documented. drug destroyed on site will be documented in the study files. the primary outcome (any hospitalization or all-cause death) will be assessed by direct telephone contact with the patient, with the contact person, or with the treating physicians ( day 3, 7, 14, 30) . due to the unquestionable nature of the primary efficacy outcome, no adjudication of the events is deemed necessary. the investigators will be allowed by the patient to obtain clinical information from discharge letters in case of hospitalization or medical treatment. all the information collected telephonically based on a predefined questionnaire and conversation notes will be documented (patient questionnaire, visits 2-6); the document will be regarded as source document. additional source documents will be represented by admission/discharge letters in the case the patient will undergo ambulatory visits or will be admitted to the hospital (documentation of outcomes). primary and secondary endpoints must be documented by written reports of the treating physicians. after termination of the phone call, all information will be transferred into the ecrf. telephone contact will occur at predefined timepoints: patients (or the first contact person) will be contacted on the day of the planned contact. in case the patient (or the first contact person) cannot be contacted, a second phone call will take place two hours later. in case of no answer, the second contact person will be immediately contacted and the same procedure will take place. if the patient (or contact persons) cannot be reached by phone, the treating physicians will be alerted due to safety reasons. thromboembolism, myocardial infarction or stroke) will be evaluated at day 3, 7, 14, 30 and 90 equivalently to the primary outcome (9.2.1). assessment of safety outcomes major bleeding and non-major clinically relevant bleeding will be evaluated at day 3, 7, 14, 30, 90 by asking specific questions on the phone (cf. question list file "crf variables list, page "phone visit", "primary outcome", "secondary outcome"). if the patient cannot be reached by phone or if clarification is needed, the treating physician of the patient will be contacted. recording of serious adverse event is described in section 10. no information on specify laboratory parameters will be routinely assessed during the course of the study as part of the study outcomes: the follow-up visits will take place telephonically. no information on vital signs will be routinely assessed during the course of the study as part of the study outcomes: all the follow-up visits will take place telephonically. no additional investigation is planned in participants who voluntarily stop the study for non-medical reasons. pre-screening (day -5 to 1) will take place according with the scenarios summarized in section 7.2 as the process of screening may vary according with individual capacities and setting of initial sars-cov2 testing. procedures for pre-screening, irrespective of the scenario: -signature of pic1 (if applicable) -discussion with the patient on study participation (pre-screen survey) -referral to the closest study center. procedures at baseline visit, irrespective of the scenario: -signature of pic2 -collection of demographic and baseline characteristics, including comorbidities and comedications -vital signs assessment: respiratory rate, heart rate, systolic blood pressure, diastolic blood pressure, body temperature, oxygen saturation, height, weight, body mass index -if not available, additional blood test analysis with point of care or standard assays. -if the subject signed pic2 and meets all of the inclusion and none of the exclusion criteria, he or she is eligible to be randomly assigned to receive enoxaparin or no therapy (randomization) -allocation to study treatment -if applicable, patients will be instructed on how to administer the study medication via personal communication, remote instructions, and/or video material. for bleeding events, subjects and family members as appropriate, will be instructed: -to seek medical attention if they develop bleeding -to contact the investigative site staff or study investigator before the next dose of study medication is due -to inform treating health care providers about study participation subjects and family members, as appropriate will also be instructed: -about the subject's risk of dvt and pe -about the signs and symptoms of dvt and pe -to seek medical attention if they develop any of these signs or symptoms -to contact the investigative site staff or study investigator as soon as symptoms develop and before the next dose of study medication is due -to inform treating health care providers about hospitalization or death. the subject's family should be instructed to have a low threshold to contact the site (a patient card is given). follow-up visits: phone contact and assessment of the primary/secondary study outcomes (day 3, 7, 14, 30, and 90), suspected serious adverse events (day 3, 7, 14, 30, and 90), vital status (day 3, 7, 14, 30, and 90), drug compliance (day 3, 7 and 14). information on symptoms potentially pointing to a study outcome or sae will be adequately collected during the follow-up visit and the patient may be instructed to seek in-person medical assistance if deemed necessary by the study personnel, i.e. in the case of a suspected thromboembolic event (dvt, pe, myocardial infarction stroke), bleeding with characteristics of severity (i.e. occurring at critical sites), substantial worsening of the respiratory symptoms compared with baseline, onset of new symptoms, sae. the sponsor's sops will provide more detail on safety reporting. during the entire duration of the study, all serious adverse events except the study outcomes as noted above will be collected and entered into the serious adverse event page of the ecrf. study duration encompasses the time from when the participant signs the informed consent until the last protocol-specific procedure has been completed (phone call at day 90). an sae is defined as any untoward medical occurrence that at any dose results in • results in death, • is life-threatening, • requires participant hospitalization or prolongation of current hospitalization, • results in persistent or significant disability/incapacity, or • is a congenital anomaly/birth defect, • any important medical event and any event which, though not included in the above, may jeopardise the participant or may require intervention to prevent one of the outcomes listed above. any other medically important condition that may be not immediately life-threatening or results in death or hospitalization but may jeopardize the participant or may require intervention to prevent one of the outcomes listed above should also usually (i.e. based on medical and scientific judgment) be considered serious. an "unexpected" adverse drug reaction is an adverse reaction, the nature or severity of which is not consistent with the applicable product information. a serious adverse reaction, the nature or severity of which is suspected to be not consistent with the applicable product information. all suspected new risks and relevant new aspects of known adverse reactions that require safety-related measures. clinical investigators and ultimately the principal investigator (pi) have the primary responsibility for sae identification, documentation, grading, and assignment of attribution to the investigational agent/intervention. information on all saes will be collected during phone follow-up. standard questionnaire (patient questionnaire, visits 2-6) will include key questions for sae screening, including the occurrence of the primary efficacy outcome (hospitalization, death), bleeding at potentially critical sites, or symptoms that may reflect an underlying and potentially severe condition of new onset. in the latter case, the severity of symptoms will be compared with the status at baseline. all saes will be fully documented in the appropriate ecrf. for each sae, the investigator will provide the onset, duration, intensity, treatment required, outcome and action taken with the investigational product. the investigator assesses the causal relationship of each sae according to the sae reporting form. an unexpected sae refers to any ae, the nature or severity of which is not consistent with the applicable product information. the investigator will promptly review saes to determine if the sae meets the criteria for a susar. the assessment by the investigator with regard to the study drug relation is done according to the following definitions:  the event started in no temporal relationship to medicinal product applied and  the event can be definitely explained by underlying diseases or other situations. related  the event started in a plausible temporal relationship to medicinal product applied and  the event cannot be definitely explained by underlying diseases or other situations. the investigator is responsible for reporting any saes to the sponsor immediately, i.e. within 24 hours using the following email address: ovidstudie@usz.ch the investigator is responsible for sae reporting to the cec according to the following details:  reporting to cec any sae which resulted in death: -without delay, and no later than 7 calendar days.  reporting to cec of fatal saes if evaluated as "suspected", "unexpected" and "drug related" (susar) -without delay and no later than 7 calendar days following awareness that event meets criteria for an susar.  reporting to cec of non-fatal saes if evaluated as "suspected", "unexpected" and "drug related" (susar): -promptly and no later than 15 calendar days following awareness that event meets criteria for a susar. the sponsor is responsible for sae reporting to swissmedic according to the following details: • compliance with the regulatory requirements of swissmedic regarding prompt reporting of unexpected saes for which a causal relationship with the study drug cannot be ruled out. reporting to swissmedic of fatal saes if evaluated as "suspected", "unexpected" and "drug related" (susar): -without delay and no later than 7 calendar days following awareness that event meets criteria for a susar; • reporting to swissmedic of non-fatal saes if evaluated as "suspected", "unexpected" and "drug related" (susars): -promptly and no later than 15 calendar days following awareness that event meets criteria for a susar. all other saes will be summed up in the annual safety report (asr), containing: -a summary of the safety profile of the drug studied as well as the safety issues that have arisen; the sponsor is responsible to prepare a dsmb charter, which will be submitted to the kek and swissmedic in due time and before the enrolment of the first patient. it is the role of the dsmb to advise the sponsor regarding the continuing safety of current participants and those yet to be recruited, as well as the continuing integrity, validity and scientific merit of the trial. a fundamental consideration is the safety of those who would be at potential risk due to their participation in the trial. the dsmb must be particularly alert to the risks inherent to anticoagulant therapy. in addition, the conduct of the study is subject to review in the context of its capability to ultimately address the scientific questions of interest, including recruitment rate, ineligibility, non-compliance, protocol violations, dropouts, completeness and timeliness of data. the dsmb may advise the sponsor and principal investigators to modify/improve specific aspects of the study conduct. the dsmb has a more circumspect role in recommending changes to the study protocol after having discussed these concerns with the sponsor and principal investigators. members of the dsmb have relevant expertise and experience in clinical trials and are aware of the responsibilities inherent in the operation of the dsmb. the dsmb includes a biostatistician knowledgeable in statistical methods used in clinical trials. all serious adverse events that have not resolved by the end of the study, or that have not resolved upon discontinuation of the subject's participation in the study, will be followed until any of the following occurs: -the event resolves, -the event stabilizes, -the event returns to baseline, if a baseline value/status is available, -the event can be attributed to agents other than the study drug or to factors unrelated to study conduct, -it becomes unlikely that any additional information can be obtained (subject or health care practitioner refusal to provide additional information, lost to follow-up after demonstration of due diligence with follow-up efforts). two treatment arms are to be compared, experimental arm with enoxaparin versus control arm without any treatment. randomization will be 1:1. objective is to demonstrate superiority of experimental treatment (enoxaparin). primary outcome of the study is any hospitalization or any-cause death within 30 days of enrolment. sample size is fixed, one interim analysis is planned at time when the outcomes of 50% of the patients have been observed. we obtained official data on fatality and hospitalization rates observed in the swiss population until 31.03.2020: a total of 12.372 patients aged 50 years or older tested positive for sars-cov-2, of whom 645 (5.2%) died and 2.350 (19.0%) were hospitalized irrespective of whether this consisted of a primary hospitalization (after evaluation at the emergency department) or a secondary hospitalization for clinical deterioration after initial ambulatory treatment. assuming that two thirds of deaths and of any hospitalizations occurred in ambulatory patients, we estimated that the primary efficacy outcome rate would occur in 15% (any hospitalization 11%, case fatality rate 4%). as we anticipate that the a substantial number of the primary endpoint is due to venous or arterial thromboembolic complications, which would be prevented by the use of prophylacticdose enoxaparin, we estimated that enoxaparin will decrease the primary efficacy outcome to 9% (rr 0.6). the following studies were also considered for estimating the benefit of enoxaparin use in medical patients and sample size calculation: -prophylactic treatment with 40 mg per day of enoxaparin subcutaneously (vs. placebo) safely reduced the risk of venous thromboembolism detected by bilateral venography or duplex ultrasonography in patients with acute medical illnesses ( -anticoagulant therapy, mainly with lmwh, appeared to be associated with better prognosis in severe covid-19 patients meeting sic criteria or with markedly elevated ddimer (4). the sample size calculation is based on the parameters = 0.05 (2-sided), power = 1− = 0.8, event rate in experimental group, = 0.09 and event rate in control group, = 0.15. the resulting total sample size is 920. to account for potential drop-outs, the total sample size was fixed to 1000. this will be the maximum sample size, no increase in sample size is planned. results will be reported in terms of risk ratios (rr) between experimental and control group, i.e. we anticipate that the estimated rr will be < 1. see details reported in the interim analysis (11.4.4). a detailed statistical analysis plan will be written up upon ethics approval. the primary efficacy outcome analysis will be conducted in the intention-to-treat (itt) population, consisting of all randomized subjects who signed a valid informed consent. descriptive statistics of the patient characteristics at baseline will include mean and standard deviation for continuous variables, median and interquartile range for the ordinal or non-normal variables, as well as numbers and percentages of total for the categorical variables. for the primary outcome, the relative risk will be calculated for the experimental group as compared to control group, with 95% confidence interval. refined analyses include the stratification variables in order to reduce unexplained heterogeneity. for that, the mantel haenszel method as well as multiple logistic regression models will be used. a more detailed statistical analysis plan for interim analysis and final analysis will be written up while patients are being recruited. all analyses will be conducted with r (r core team 2019). rmarkdown will be used for dynamic reporting. r-packages used for sample size determination and study design: iabin 1.0, gsdesign 3.0.1, and trialsize 1.3.the corresponding reporting guideline for randomized superiority trials is consort guideline. heterogeneity analysis to study treatment effects of enoxaparin (versus no treatment) will be conducted in specific subgroups of patients categorized by sex, age-groups, renal function, and concomitant antiplatelet therapy. groups will be compared for all the secondary outcomes. results will be reported as relative risk and they will be calculated for the experimental group as compared to control group, with 95% confidence interval. a single interim analysis is planned. the aim of the interim analysis is to stop the trial early for efficacy (superiority) or futility. a group-sequential approach will be used, based on stopping boundaries with o'brian-fleming design (obf). obf is accepted by regulators and ich-e9 guidelines. design specifications: a symmetric 2-sided group sequential design with 2 analyses and a total sample size of 997 patients will be used, power will be 80%, 1-sided significance level will be 0.025 (type i error). bounds were derived using obf boundary. the following plot shows an illustration of the specification. the analysis of safety outcomes will be conducted in the safety population, including patients who received at least one dose of study drug (enoxaparin) or who were alive 12 hours after randomization. the ovid study will be conducted as a national research initiative involving all the five university hospitals and two large cantonal hospitals in ticino under the coordination of a local covid commitee. at least one patient room is required for enrolment, ideally located outside main hospital facilities to avoid transmission of covid to staff and other patients 2) ability to locally perform rapid blood cell count (hemoglobin, platelet count) and creatinine tests as some covid-19 outpatients may have no recent (<3 months) results of blood tests mandatory for enrolment. if point of care tests are used, these should ideally be performed outside the patient rooms. parking lot nearby the patient rooms because covid patients may not use public transport. signed contract with university hospital zurich (recruitment and study procedures must be in accordance with gcp standards and performed according with at least one of the aforementioned scenarios). each participating center has already received a contract examined by unitectra (clinical research agreement), which includes data on financing, results, data and liability, etc… the sponsor investigator is responsible for the implementation and maintenance of a quality management system, including the performance of quality controls in the form of monitoring and, if necessary, quality assurance audits. the sponsor investigator provides study-specific sops and wis to the participating centres. the investigator is responsible for ensuring that all persons involved in the trial are adequately trained for their tasks. this ensures that the test procedures are carried out in a standardized manner and that the applicable guidelines and laws are observed the study will strictly follow the protocol. if any changes become necessary, they must be laid down in an amendment to the protocol. all amendments of the protocol must be signed by the sponsor-investigator and will be submitted to cec and swissmedic. the investigators will use electronic case report forms (ecrf), one for each enrolled study participant, to be filled in with all relevant data pertaining to the participant during the study. all participants who signed the informed consent (pic2) have to be documented on a screening log. the investigator will document the participation of each study participant on the enrolment log. for data and query management, monitoring, reporting and coding an internet-based secure electronic data capture system redcap, which is hosted by the clinical trials centre (ctc) zurich will be used for this study. it is the responsibility of the investigator to assure that all data in the course of the study will be entered completely and correctly in the respective data base. corrections in the ecrf may only be done by the investigator or by other authorised persons. in case of corrections the original data entries will be archived in the system and can be made visible. for all data entries and corrections date, time of day and person who is performing the entries will be generated automatically. ecrfs must be kept current to reflect participant status at each phase during the course of study. participants must not to be identified in the ecrf by name. appropriate coded identification (e.g. participant number) must be used. it will be assured that any authorised person, who may perform data entries and changes in the ecrf, can be identified. a list with signatures and initials of all authorised persons will be filed in the study site file and the trial master file, respectively. the investigators assure to perform a complete and accurate documentation of the participant data in the ecrf. all data entered into the ecrf with exception of (for which data the ecrf will be source data to be specified for each study) must also be available in the individual participant file either as print-outs or as notes taken by either the investigator or another responsible person assigned by the investigator. the following documents are considered source data, including but not limited to:  ecrf (demographic and baseline characteristics, vital signs, comedications, laboratory parameters, sae, study outcomes),  nurse records, records of clinical coordinators, and  medical records from other department(s), or other hospital(s), or discharge letters and correspondence with other departments/hospitals. source data must be available at the site to document the existence of the study participants and substantiate the integrity of study data collected. source data must include the original documents relating to the study, as well as the medical treatment and medical history of the participant. study protocol. ongoing maintenance and use of this software is contractually agreed upon between the study sponsor and the data management department of the ctu zurich. appropriate coded identification (e.g. pseudonymisation) is used in order to enter subject data into the database. all data entered into ecrfs is transferred to a mysql database using encryption post filtering and sanitization to various relational database tables. the server hosting the edc system and the database is kept in an off-site locked serverroom. only system administrators have direct access to the server and back-up tapes. a role-based user concept with personal login and passwords (e.g. for site investigator, statistician, monitor, administrator etc.) regulates permission for each user to access the system and database when required. within each project, there are role-and user-based settings to control access to various functionality and modules, such as being able to export data, to enter data, export reports and view the logging records. another feature called data access groups, can be implemented to help segregate users so that the data they enter is only accessible by someone in their group, especially useful for multi-centric studies where the data entered by one institution should not be accessible or viewable by others within the same project. a current list with signatures and names of all authorized study personnel with access to the study records will be filed in the study site file and the trial master file, respectively. a built-in data logging tool (audit trail) ensures that any changes to the project or user activity (date and time stamp and user log), including contextual information (e.g. the project record being accessed), are continuously tracked in real-time and accessible online or via downloadable audit table. a multi-level back-up system is in place. whole system internal back-ups including the database are run several times per day and an additional external back-up onto tape once a day. the back-up tapes are stored in a secure place in a separate building. ecrfs are kept current to reflect subject status at each phase during the course of the study. for ad interim (if applicable) and final analyses, data files are extracted from the database in csv (case-delimited) format, typically supported by microsoft excel, sas, stata, r, or spss software systems. direct import into these statistical packages is advised for best data analyses. this study foresees the use of r for statistical analysis of study outcome. the study database will be securely stored by ctu zürich for at least 15 years (after the regular end or a premature termination of the respective study). the edc system supports data checks completeness and plausibility. furthermore, selected data points are cross-checked for plausibility with previously entered data for that participant. additional central data validity checks against pre-determined parameters are run either automatically or ad hoc, to detect inconsistencies and identify missing data for source data verification. monitoring prior to the start and during the course of the study will help to follow up the progress of the clinical study, to assure utmost accuracy of the data and to detect possible errors at an early time point. the sponsor-investigator organises professional independent monitoring for the study and will collaborate with the clinical trials center (ctc) of the university hospital zurich. according to the ctc's monitoring sop the extent and nature of monitoring activities based on the objective and design of the study will be defined in a study specific monitoring plan. during the covid-19 pandemic monitoring will be performed by remote techniques as defined in the monitoring plan. see the attached monitoring plan. a quality assurance audit/inspection of this study may be conducted by the competent authority or cec, respectively. the quality assurance auditor/inspector will have access to all medical records, the investigator's study related files and correspondence, and the informed consent documentation that is relevant to this clinical study. the investigator will allow the persons being responsible for the audit or the inspection to have access to the source data/documents and to answer any questions arising. all involved parties will keep the patient data strictly confidential. direct access to source documents will be permitted for purposes of monitoring, audits and inspections. not applicable. by signing the clinical trial protocol, the investigator agrees on the use of the results of this clinical trial for publication and information for medical and industrial professionals. the findings of this clinical trial including the interim analysis will be published in a scientific journal or presented at a scientific meeting and may be used for pooled analyses with similar trials. publication of clinical trial results requires mutual agreement between the investigators and the sponsor. any publication of the clinical trial data by the sponsor or investigators will be wholly consistent with the integrated report in accordance with the ethical principles of the declaration of helsinki. all publications will follow the uniform requirements for manuscripts submitted to biomedical journals (www.icmje.org, october 2008). this investigator-initiated study will be funded by the clinic of angiology, usz and the clinic of cardiology, inselspital. various applications for public funding have been conducted, including university zurich, innovation pool usz, swiss red cross froundation, johanna dürmüller-bol foundation. additional public funding will be requested as needed. in case of involvement of centers from other countries, potential co-sponsors will apply for separate national public fundings. insurance is covered by "versicherung für klinische versuche und nichtklinische versuche" by zürich versicherungs-gesellschaft ag (policy no: 14.970.888). any damage developed in relation to study participation is covered by this insurance. so as not to forfeit their insurance cover, the participants themselves must strictly follow the instructions of the study personnel. participants must not be involved in any other medical treatment without permission of the principal investigator (emergency excluded). medical emergency treatment must be reported immediately to the investigator. the investigator must also be informed instantly, in the event of health problems or other damages during or after the course of study treatment. the investigator will allow delegates of the insurance company to have access to the source data/documents as necessary to clarify a case of damage related to study participation. all involved parties will keep the patient data strictly confidential. a copy of the insurance certificate will be placed in the investigator's site file. 37 6.1 general study design and justification of the design unblinding procedures (code break) 47 8.2 administration of experimental and control interventions data collection and follow-up for withdrawn participants study flow chart/table of study procedures and 51 9.3.1 pre-screening period (day -5 to day 1) corriere dell sera -data analysis. «the real death toll for covid-19 is at least 4 times the official numbers cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (covid-19) pandemic clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy time to consider histologic pattern of lung injury to treat critically ill patients with covid-19 infection covid-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and followup prediction models for diagnosis and prognosis of covid-19 infection: systematic review and critical appraisal analysis of deaths during the severe acute respiratory syndrome (sars) epidemic in singapore: challenges in determining a sars diagnosis potential effects of coronaviruses on the cardiovascular system: a review chest radiographic and ct findings in novel swine-origin influenza a (h1n1) virus (s-oiv) infection autopsy findings in eight patients with fatal h1n1 influenza h1n1-induced venous thromboembolic events? results of a single-institution case series acute pulmonary embolism and covid-19 pneumonia: a random association? venous and arterial thromboembolic complications in covid-19 patients admitted to an academic hospital in incidence of thrombotic complications in critically ill icu patients with covid-19 prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia high incidence of venous thromboembolic events in anticoagulated severe covid-19 patients thrombotic complications of patients admitted to intensive care with covid19 at a teaching hospital in the united kingdom is covid evolution due to occurrence of pulmonary vascular thrombosis? incidence of thrombotic complications in critically ill icu patients with covid-19 prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia covid-19 experience in high risk of thrombosis in patients in severe sars-cov-2 infection: a multicenter prospective cohort study pulmonary embolism in covid-19 patients: awareness of an increased prevalence acute infections and venous thromboembolism cytomegalovirus infection is associated with venous thromboembolism of immunocompetent adults--a case-control study thromboembolic events in patients with severe pandemic influenza a/h1n1 a comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. prophylaxis in medical patients with enoxaparin study group rivaroxaban for thromboprophylaxis after hospitalization for medical illness external validation of the risk assessment model of the international medical prevention registry on venous thromboembolism (improve) for medical patients in a tertiary health system influenza epidemics and acute respiratory disease activity are associated with a surge in autopsy-confirmed coronary heart disease death: results from 8 years of autopsies in 34,892 subjects association of coronavirus disease 2019 (covid-19) with myocardial injury and mortality clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (covid-19) association of cardiac injury with mortality in hospitalized patients with covid-19 in wuhan, china covid-19 and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: what is the evidence? jama endothelial cell infection and endotheliitis in covid-19. lancet. 2020. 41. isth interim guidance on recognition and management of coagulopathy in covid-19 the versatile heparin in covid-19 evaluation of the effects of low molecular weight heparin on inflammation and collagen deposition in chronic coxsackievirus b3-induced myocarditis in a/j mice thrombosis-uk. practical guidance for the prevention of thrombosis and management of coagulopathy and disseminated intravascular coagulation of patients infected with covid-19 covid-19 and its implications for thrombosis and anticoagulation. blood. 2020. 47 rivaroxaban for extended thromboprophylaxis after hospitalization for medical illness: pooled analysis of mortality and major thromboembolic events in 16,496 patients from the magellan and mariner trials extended prophylaxis for venous thromboembolism after hospitalization for medical illness: a trial sequential and cumulative meta-analysis thromboprophylaxis with enoxaparin and direct oral anticoagulants in major orthopedic surgery and acutely ill medical patients: a meta-analysis treatment of venous thromboembolism in patients with cancer: a network meta-analysis comparing efficacy and safety of anticoagulants critical appraisal of international guidelines for the prevention and treatment of pregnancy-associated venous thromboembolism: a systematic review american society of hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients american society of hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy american society of hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients thrombosis prophylaxis in the acutely ill medical patient: insights from the prophylaxis in medical patients with enoxaparin (medenox) trial the task force for the diagnosis and management of acute pulmonary embolism of the european society of cardiology (esc) rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty aspirin or rivaroxaban for vte prophylaxis after hip or knee arthroplasty rivaroxaban for thromboprophylaxis in acutely ill medical patients the incidence of heparin-induced thrombocytopenia in medical patients treated with low-molecular-weight heparin: a prospective cohort study subcommittee on control of anticoagulation of the s, standardization committee of the international society on t, haemostasis. definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients lowmolecular-weight heparin and mortality in acutely ill medical patients extended-duration venous thromboembolism prophylaxis in acutely ill medical patients with recently reduced mobility: a randomized trial the following information (at least but not limited to) should be included in the source documents:• demographic data (age, sex) • inclusion and exclusion criteria details • participation in study and signed and dated informed consent forms • visit dates • medical history and physical examination details • key efficacy and safety data (as specified in the protocol) • aes and concomitant medication • results of relevant examinations • laboratory printouts • dispensing and return of study drugs • reason for premature discontinuation • assignment to treatment groupthe data collected during the phone calls (day 3, 7, 14, 30 and 90) will be entered directly in the ecrf. additionally, the site reports from the visits (in-hospital visit, as well as phone visits) will be imported into the electronic patient chart of the study centers. all study data must be archived for a minimum of 10 years after study termination or premature termination of the clinical trial. any patient files must be archived for the longest possible period of time according to the feasibility of the investigational site, e.g. hospital, institution or private practice for the present clinical study, the electronic data capture (edc) software redcap (www.project---redcap.org) will be used for data processing and management. redcap was developed by an informatics core at vanderbilt university in 2004, with ongoing support from us national center for research resources (ncrr) and us national institute of health (nih), grants nih/ncats ul1 tr000445. redcap was specifically developed around hipaa security guidelines and is gcp-compliant and fulfills the swiss regulatory requirements regarding the collection of patient data in clinical trials or noninterventional studies and patient registries and the swiss/eu data protections laws. operating requirements include a linux, unix, windows or mac interface. the system requires a smtp e-mail server, is accessed via php web-based front end (e.g. microsoft iis or apache) and runs on a mysql database server, hosted by the clinical trials center of the university hospital zurich, which holds a redcap end-user license agreement for this edc system. data collection occurs via electronic case report forms (ecrfs), which are generated via study-specific data dictionary defined in an iterative self-documenting process by members of the research team with planning support from the data management department of the clinical trials center, university hospital zurich, switzerland (ctu zurich). the iterative development and testing process results in a well-planned data collection strategy in keeping with the outcome parameters and procedures defined in the 